INFANT FEEDING 



ROYSTER 




Class ^Ukui. 
Book Ll 



Ju. 



Copyright}^", 



COPYRIGHT DEPOSm 



A HANDBOOK 

OF 

INFANT FEEDING 



illllllilliiliiiiilllii 

I A HANDBOOK I 



OF 



INFANT FEEDING 



BY 

LAWRENCE T. ROYSTER, M.D. 

i' 

Attending Physician Bonney Home for Girls and Foundling 

Ward of the Norfolk Society for the Prevention 

of Cruelty to Children, Physician-in-Charge 

of King's Daughters' Visiting Nurse 

Clinic for Sick Babies. 



ILLUSTRATED 



ST. LOUIS 
C. V. MOSBY COMPANY 
1916 



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^^v 



Copyright, 19 i6, by The C. V. Mosby Company 



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, n/C 



FEB 23 1916 ^_ ^^ 

The C. V. Mosby Company 
St. Louis 



'GI.A418971 



TO THE 
OVERWORKED AND UNDERPAID GENERAL PRAC- 
TITIONER WHO MUST OF NECESSITY BE NOT 
ONLY THE FAMILY PHYSICIAN BUT THE 
ALL-ROUND SPECIALIST THIS VOLUME 
IS AFFECTIONATELY DEDICATED 



PREFACE 



THE idea of this little book was suggested to me 
as a result of consultation on feeding cases 
with many general practitioners. There is very lit- 
tle in it that cannot be found in most standard 
works, but in order to gain the necessary informa- 
tion the busy practitioner must spend much time 
reading many pages. Of necessity, most of the in- 
fant feeding is conducted by the family physician 
and it is a source of regret that many of these cases 
are handled in an unscientific manner. 

The purpose of this book, then, is to furnish the 
essentials and only the essentials of infant feeding 
in a compact and succinct form. 

The desirability of expressing the elements which 
go to make up the infant's dietary in the form of 
approximate percentages has been emphasized. It 
is not claimed by any advocate of this method of 
expression that it does more than approximate ac- 
curacy. To attain an accurate percentage would re- 
quire the services of an expert chemist in a well reg- 
ulated laboratory. The exact composition of each 
quantity of milk would have to be determined and 
the ingredients combined by weight and not by vol- 
ume. This is, of course, impracticable. The value 
of the percentage method of expression lies in the 

7 



8 INFANT I^EEDING. 

fact that it enables us to reduce or increase the va- 
rious food elements with approximate accuracy in 
accordance with the needs of the infant. 

The author realizes the fact that the book con- 
tains many imperfections, and that the specialist in 
diseases of children will find nothing in it new or 
original, but he hopes that those into whose hands 
it may fall will remember the purpose of the book 
and the needs of those for whom it was written, 
and that it may not be viewed with a too critical 
eye. 

The works of many leading authorities on infant 
feeding have been consulted and quoted liberally 
and without reserve and to these the author hereby 
makes public and grateful acknowledgment. 

To his friend, Dr. John Lovett Morse, who has 
so kindly contributed the very valuable chapter on 
stools the author desires to express his sincere grat- 
itude. 

To Mrs. A. T. Robertson, his secretary, the au- 
thor acknowledges a large debt for the preparation 
of manuscript and reading of proof. 

L. T. ROYSTER. 

Taylor Bldg., 
Norfolk, Va. 



CONTENTS 

CHAPTER I. 

Page 
Intrc luction 11 

CHAPTER n. 
Resources 18 

CHAPTER HI. 
Growth and Development 27 

CHAPTER IV. 
The Stools in Infancy 31 

CHAPTER V. 
Breast Feeding 47 

CHAPTER VI. 
The Handling of a Normal Baby on the Bottle 54 

CHAPTER VII. 
The Care of the Premature Infant 63 

CHAPTER VIII. 
Digestive Disturbances of the Breast Fed Infant 68 

CHAPTER IX. 
Digestive Disturbances in Artificially Fed Infants 74 

CHAPTER X. 
Handling of Difficult Feeding Cases S3 



Page 
CHAPTER XL 

Infant Feeding During the Second Year 91 

CHAPTER Xn. 
Marasmus ^ 97 

CHAPTER Xni. 
Infectious Diarrhea 101 

CHAPTER XIV. 
Preparation of Formulae 115 

CHAPTER XV. 
Caloric Needs of Infants 132 

APPENDIX. 

Human Milk — Barley Water — Whey — Eiweiss Milch, the 
Casein Milk of Finkelstein — Condensed Milk — Malt 
Sugar — Peptonization — Buttermilk — Batter Bread 
(Spoon Bread) 136 



INFANT FEEDING 



CHAPTER I. 
INTRODUCTION. 



THE study of dietetics has occupied a very much 
larger place in medical literature during the 
past twenty-five years than in any other period of 
medicine. The larger portion of this work has re- 
lated to the feeding of infants ; indeed, to the care- 
ful and scientific investigation of the relation of cer- 
tain food elements to the infant economy is due the 
wider interest in dietetics in general. The investi- 
gation of infant feeding along scientific lines was 
very recently a pioneer work, and many important 
discoveries have been made which have revolution- 
ized the subject. Almost as soon, however, as a 
new discovery was made or emphasis was placed on 
a certain food element there immediately sprang 
up, at least among the general practitioners of med- 
icine, ''a new method of feeding infants." This is 
most unfortunate, because there is no such thing as 
a ''method of feeding infants" beyond the two well 
recognized methods of breast feeding and artificial 
feeding. In the one we have nature's method, which 
is the best ; in the other we have the artificial meth- 
od which we are compelled to use from time to 

11 



12 INI^ANT i^EjEDING. 

time when called upon to supplement or entirely 
supplant maternal nursing. 

The great importance of this subject can be real- 
ized only when we consider a few statistical facts. 
Statistics as we know are proverbially misleading, 
proving usually what is the wish of the compiler; 
however, only through these means can we make 
comparisons. The percentage of children dying 
during the first two years of life has been variously 
estimated and although these estimates are far 
from being accurate they bring us to two very im- 
portant and shocking conclusions : 

First, that the mortality among children during 
the first two years of life is so far out of propor- 
tion to the normal death rate at all other ages that 
we must feel that something is radically wrong. 

However startling this may be, the second fact 
is still more striking and that is that the vast major- 
ity of children dying during the first two years of 
life are bottle fed babies. Statistics differ, but af- 
ter studying a large number of them and taking 
into consideration the conditions surrounding each 
particular set, I am convinced that the ratio is prob- 
ably only one breast fed baby in every twelve 
deaths. It must not be inferred from this that ar- 
tificial feeding per se is the cause of the large num- 
ber of deaths at this age, for we must also take into 
consideration certain physical and economic factors 
which are co-active in causing the cessation of 
breast feeding and thereby contribute to the exces- 
sive mortality. There are, for instance, climatic 



INTRODUCTION. 13 

conditions which either in themselves produce the 
condition known as "summer diarrhea'' (heat stroke 
theory), or under whose influence certain bacteria 
develop which cause the diarrhea. The latter theory- 
is more than likely correct. ("Infectious Diarrhea.'') 

Yet I am certain that very many unnecessary 
deaths occur from improper feeding alone. We are 
brought to the unavoidable conclusion that an in- 
tensive study of infant mortality must begin with 
the question of artificial feeding. Moreover, this 
problem is essentially one for the general prac- 
titioner in medicine for undoubtedly upon him rests 
the burden of feeding the vast majority of infants. 

It is seldom that we can improve upon nature. 
Nature has supplied the infant with a food which 
is sufficient for its needs at least during the greater 
part of the first year of life. This is mother's milk 
intended for the baby and supplying all the ele- 
ments necessary for heat production and tissue 
building during this period, in a solution that is 
adaptable to the processes of infant digestion. No 
laboratory method can combine these elements so 
that they will be assimilated to the same extent as 
the natural product. Aside from this, nature sup- 
plies an indefinable "something" which specifically 
influences the young of the same species; whether 
this is an as yet undiscovered secretion of the mam- 
mary glands or the absorption of the secretion of 
some other gland of the body, we do not know. 
This indefinable something not only aids the infant 
in digesting the mother's milk but apparently pro- 



14 INFANT FEEDING. 

tects it against the invasion of infection while it is 
being breast fed. In the light of these observa- 
tions, no argument is necessary to make us use ev- 
ery endeavor to keep the child at the breast as long 
as is practicable, and during certain acute illnesses 
to supply human milk from another source at any 
cost. One of the most valuable assets in the child 
life of any community is a wet nurse register which 
may be established under conditions outlined by 
several observers. When it is not possible to use 
maternal feeding exclusively, or to substitute a wet 
nurse, we may resort to mixed feeding because 
even a very small amount of human milk will cause 
the infant to assimilate a modification of cow's milk 
very much better. 

When it is finally determined that the continua- 
tion of breast feeding is impracticable, resort must 
be had to artificial methods which may be employed 
to supplement or supplant maternal feeding. The 
term ''artificial feeding" today is practically syn- 
onymous with feeding by means of modified cow's 
milk. Much error has arisen in the minds of both 
the laity and the profession as to the true sig- 
nificance of this term. This error is due to igno- 
rance of the facts, as evidenced by the frequency 
with which we hear from both physicians and moth- 
ers the expression, ''the baby has been tried on mod- 
ified milk and cannot take it." 

"Modified milk" means simply cow's milk dilut- 
ed, and usually some carbohydrate is added. Ob- 
viously success in feeding children on modified milk 



INTRODUCTION. 15 

depends on the proper dilution, for it is evident 
that if we take a. child of three months and feed that 
child on a modification consisting of two-thirds 
cow's milk and one-third water without due regard 
to the addition of carbohydrates or other ingredients, 
we have a modification which is based on error, con- 
sequently it could not be expected to meet the re- 
quirements of the case. Whereas, if we first ascer- 
tain the approximate percentage of various ingre- 
dients which a child of this age is likely to assimi- 
late, we may then anticipate a successful handling 
of the case. For many years, and even too often at 
the present time, proportions of various resources 
are used empirically and guess work plays a very 
important part in their employment and arrange- 
ment. Fortunately for the infant, through increas- 
ing knowledge, there has developed a more definite 
and scientific procedure by which we are enabled to 
adapt the various food elements to the require- 
ments of the individual infant. Regardless of how 
the infant is fed, whether on simple dilutions of 
whole cow's milk or by the use of so-called top milk, 
or by means of cream, milk and water, the physician 
should always be able to state, at least approxi- 
mately, the percentage of fat, carbohydrate and pro- 
teid which is given the infant in twenty-four hours, 
for only by this means can be determined, and 
by an intelligent examination of the stools, the 
amount of vomiting, etc., what element is causing 
trouble and thereby be enabled to adjust accurate- 
ly the amount of the particular element. 



16 INFANT i^EE^DING. 

I wish to urge, therefore, very strongly the feed- 
ing of infants in terms of definite percentages of 
the various elements. In order to do this, the phy- 
sician in charge must accustom himself to thinking 
in percentages rather than in quantities. The com- 
plaint is frequently made that the so-called per- 
centage method entails too much trouble and re- 
quires too much mathematics. On the contrary, 
I hope to demonstrate that it is a very simple pro- 
cedure. 

The average milk from a herd of cows is usual- 
ly taken as — 

Fat Sugar Proteid 

4 4.50 3.20 

while that of human milk is — 

Fat Sugar Proteid 

4 7 1.50 

It was first supposed that cow's milk so diluted 
and added to as to make it conform as nearly as 
possible to the percentages of human milk was all 
that was necessary. It was very soon discovered 
that such was not the case since there is a very 
great difference in the infant's power to digest the 
elements in cow's milk and those in human milk. 
Cow's milk is suited to the requirements of the 
calf whose digestion is much more powerful than 
that of the infant. In fact, in a very short time 
after birth the calf is able to digest hay, grass 
and other substances in addition to or in place of 
its mother's milk. The human infant requires not 



INTRODUCTION. 17 

only a different proportion, but also that indefin- 
able something to which we have already alluded 
which is supplied by the human mother and not 
by any other animal. Moreover, as a rule, the 
baby can take smaller proportions of the same ele- 
ments in cow's milk than in human milk and, gen- 
erally speaking, can assimilate a higher proportion 
of casein than it was once thought and can take 
smaller proportions of fat. Therefore, a complete 
rearrangement is necessary in which we are to be 
guided by the study of the child's nutrition, weight 
and the examination of stools. In order to render 
the elements of cow's milk more digestible, we make 
use of various substances which the modern stu- 
dent of child dietetics refers to as ''resources." 



CHAPTER 11. 
RESOURCES. 

THE three principal resources on which we must 
rely in feeding infants are those contained nor- 
mally in cow's milk, namely — fat, carbohydrate 
(sugar), and proteid. Many methods have been 
devised for the more or less definite proportioning 
and rearranging of these elements, such as simple 
dilutions of whole milk and so-called top milk in 
which we use either the top third, containing 10 
per cent fat, or the top half, containing 7 per cent 
fat, of a quart bottle which has been allowed to 
stand long enough for the cream to rise (gravity 
cream) ; and by means of cream and skim milk, 
in which the upper six ounces of a quart bottle are 
removed by means of a dipper, thus giving us a 16 
per cent cream, that is, a cream containing 16 per 
cent fat. The remainder of this bottle is skim milk. 
For many years, the proteid received most of 
the blame when modified milk did not agree with 
the infant, consequently an effort was made to re- 
duce the proteid to an infinitesimal percentage. As 
time went on and our knowledge increased, it was 
discovered that proteid did not cause the harm it 
was thought and fat caused more harm than was 
originally supposed. Then followed the period of 

18 



RESOURCES. 19 

high proteid and low fat proportions. Close upon 
this observation came the discovery that sugar in- 
tolerance was very quickly established in many chil- 
dren, consequently sugar came in for its share of 
blame. We recognize today, however, that an in- 
tolerance may be established when any food in- 
gredient is used unwisely, hence the necessity for 
adjusting every food formula to the peculiar needs 
of the individual infant. 

Fat. — Fat is primarily a heat producer and the 
greatest need during early infancy. The fat of 
cow's milk is more difficult to digest than that of 
human milk, consequently its administration should 
be handled carefully, beginning with a low percent- 
age and increasing very gradually until a safe per- 
centage is reached. From one to three per cent 
forms a safe amount for the average healthy baby. 
Under no circumstances do I ever allow myself to 
use more than four per cent and this exceedingly 
rarely. I believe that recent writers attribute more 
harm to fat than it deserves, although I admit that 
it must be guarded more carefully than any of the 
elements. It has been popularly believed for a long 
time that fat was laxative, but if given in too large 
proportions experience teaches us that soap is 
formed and the waste product is excreted as a hard, 
chalky fecal mass, thus producing constipation and 
indigestion. While proteids do not cause the 
amount of trouble that was formerly supposed, a 
proteid intolerance is frequently established, and I 
am not willing to use an excessively high proteid 



20 INI^ANT I^EEDING. 

content in the baby's food, certainly not in the care 
of a young healthy baby. 

The principal difficulty in the protein metabol- 
ism is the strain on the excretory system. A pro- 
teid indigestion is more difficult to recognize than 
that caused by either fat or sugar, but for practi- 
cal purposes a careful examination of the stools 
will determine that the fat is not at fault and if 
we know that we have a moderate sugar percent- 
age, we can safely assume that proteid indigestion 
is causing the trouble. The general value of the 
high percentage of proteids is in those cases of 
fat and sugar intolerance, especially of the subacute 
and chronic type so frequently found in late infancy 
(Finkelstein type). In these cases the higher pro- 
teid percentage is not only well borne, but is dis- 
tinctly advantageous from a therapeutic standpoint. 
The exact form of proteid that gives the best re- 
sult has not yet been determined. In the gastric 
type of indigestion we find proteid of great value. 
It is wiser, however, in this type to give it in the 
form of whey or soluble proteid to the exclusion of 
casein. 

Sugar. — The majority of children whose feed- 
ing has been started wisely thrive admirably on 
milk sugar, which is a normal content of both hu- 
man and cow's milk, during the whole of infancy, 
and the milk sugar of commerce mixes well with 
the sugar already in every simple milk mixture. 
There are times, however, when the child does not 
thrive on what appears to be a perfectly rational 



Ri:SOURCES. 21 

formula with milk sugar. In these instances it 
will be found advisable, for some unknown reason, 
to change to malt sugar, or rather the mixture of 
dextrin and maltose which is the most available 
malt sugar on the market. Whether this is due 
to the simple change of taste, thereby causing a 
stomachic effect, or whether there is a chemical rea- 
son we are not yet prepared to state. 

There are instances of milk sugar indigestion 
supposed to be due to fermentation but since there 
is great discussion as to the relative fermentability 
of milk and malt sugar we are not quite sure on 
this point. Of one thing I am thoroughly con- 
vinced, that is, that higher percentages of fat can 
be assimilated by the average infant in the pres- 
ence of malt than in the presence of milk sugar. 
Whether this is an advantage or not must be de- 
termined by the individual case. Malt sugar has 
been of greater use in my experience after acute 
conditions than in chronic. 

Starches.^-The routine use of starches in in- 
fant feeding is not necessary. Their food value is 
very slight, hence the main indication for their 
use is in breaking up or preventing, through pure- 
ly mechanical action, the hard casein curds. It re- 
quires a definite amount of starch to accomplish 
this. It is desirable, therefore, to use a starch solu- 
tion to the amount of 75 per cent of total twenty- 
four hour quantity, and not of the amount of cream 
and skim milk, although this has frequently been 
done. As a general rule, starch is not added to the 



22 INFANT FEEDING. 

food of young infants, yet it has been proven of late 
that young infants digest starch as well as older 
ones do. It is added more frequently to the food 
of older babies because it is found that they most 
frequently need it. It is contended by some ob- 
servers that starch directly influences the absorp- 
tion of sugars. 

Alkalies. — The action of alkalies is not definite- 
ly known. It is very generally accepted that they 
delay the process of coagulation of casein and by 
so doing promote the more rapid emptying of the 
stomach thus allowing most of the milk to pass 
into the intestines from the stomach before the 
coagulation occurs. If we accept this view, they 
would seem more valuable in gastric than in in- 
testinal indigestion and should be used in definite 
proportions to the amount of cream and milk and 
not to that of the total quantity. According to 
some, they increase the flow of hydrochloric acid 
and delay the pyloric opening and consequently 
delay the emptying of the stomach and promote the 
saponification of the fat. The routine use of alka- 
lies is not a necessity. Lime-water, bicarbonate of 
soda and sodium citrate are used by various inves- 
tigators, but lime-water at the present moment re- 
mains the most popular. 

Peptonization. — A number of years ago, pepton- 
ization played a very important part in infant feed- 
ing, but with increased knowledge of infant meta- 
bolism it has become possible to correct the dis- 
proportions of diet by changing the proportions of 



RESOURCES. 23 

food elements. There still remains a limited num- 
ber of cases where peptonization for a short time 
does good. When used at all, it is well to start 
with complete peptonization and then gradually de- 
crease both the amount of peptonizing material and 
the time of peptonization until we have returned to 
the raw product. It is a great mistake to feed pre- 
digested food for too long a time because in this 
way the digestive power of the infant is decidedly 
lowered. 

Whey. — Whey forms a valuable and often un- 
appreciated addition to our armamentarium. In 
milk there are two principal forms of protein ; case- 
in, which is largely insoluble, and the soluble or 
whey proteid. It is frequently desirable to use a 
soluble proteid to the exclusion of casein or in ad- 
dition to it in larger proportion than would occur 
in the amount of skim milk used. We make use 
of whey alone for longer or shorter periods, or as 
a diluent in the milk modification, which gives us 
a large proportion of the soluble proteid and a 
small proportion of casein (split proteid) thus en- 
abling the infant digestion to gradually take care 
of the casein. It is especially valuable after acute 
indigestion in aiding the patient to return to a 
stronger milk formula. The ingredients of whey 
vary somewhat according to whether we use skim 
milk or whole milk in its preparation, the skim 
milk furnishes us no fat in the resulting whey ; the 
whole milk giving approximately .90 per cent. 

Acids. — For all practical purposes the only acid 



24 INFANT FEE^DING. 

used in infant feeding is lactic acid, which in the 
form of buttermilk is at times a very useful aid, 
made either from whole milk or fat free (skim) 
milk as may be indicated. This forms a connect- 
ing link in milk composition between whey and 
precipitated casein. In making buttermilk any 
strain of Bulgaricus may be used if lactic acid is 
our object, but if the buttermilk is intended as a 
vehicle for the bacillus Bulgaricus, there are very 
few strains that are of value which are obtainable 
in this country. In the latter case, it is probably 
preferable to administer the bacilli in solution sep- 
arately. 

Precipitated Casein. — Precipitated casein has re- 
cently been given marked prominence through Fin- 
kelstein and his students. I do not think the in- 
dications for its use are altogether clearly under- 
stood in spite of many authorities who hold con- 
trary opinions, but undoubtedly in those cases of 
extreme carbohydrate intolerance, and especially 
where a fat intolerance exists at the same time, pre- 
cipitated casein becomes a very valuable agent. 
This is especially true in the chronic cases of maras- 
mus in the older infants of the Finkelstein type in 
whom is almost always a carbohydrate and fat in- 
tolerance. There is also a limited field of useful- 
ness in gastric indigestion in younger children. 

Condensed Milk and Proprietary Foods. — Per- 
sonally, I rarely if ever find indication for either 
of these resources. In traveling long distances with 
an uncertain milk supply on the journey, I think 



RESOURCES. 25 

one is justifiable in using condensed milk, but even 
here, where milk laboratories, or at least certified 
milk, can be found in almost all large cities, as- 
suring the preservation of milk for at least three 
or four days under proper conditions of handling, 
it v^ould seem that their field of usefulness is again 
limited. The apparent tolerance of infants to con- 
densed milk "when other forms of modification have 
failed'' is undoubtedly dependent on the low fat 
and protein plus a tolerance for cane sugar. In or- 
der to prove this, I have frequently given a child 
who seemed to furnish indications for condensed 
milk, a formula of modified cow's milk exactly cor- 
responding with the condensed milk dilution and 
found that they did equally as well. Alluding to 
proprietary foods, I, of course, allude to those which 
are used with milk dilutions. These are undoubt- 
edly dependent for their value on the malt sugar 
contained. The very wide use of both condensed 
milk and certain proprietary foods shows to my 
mind at least, as stated above, very clearly that in- 
fants have a higher tolerance for various sugars 
than we have hitherto supposed and also suggests 
the very important caution that too high percentage 
of sugar may give rise very quickly to sugar intol- 
erance which, when once established, is frequently 
very difficult to overcome. 

Sterilization and Pasteurization. — Primarily both 
of these procedures are useful where the purity of 
the milk supply is in doubt, and when this is the 
case, I invariably pasteurize or boil the milk. 



26 INFANT FE:EDING. 

Where pure milk is assured, neither is necessary. 
Occasionally, however, in the case of the hard 
casein curds in the stools, with or without colic, 
boiling for even a limited period seems to inhibit 
their formation. The digestibility of the milk 
through these processes does not seem to be im- 
paired, but in some instances seems rather to be 
increased. In other cases where it is deemed ad- 
visable to use heated milk for any long period of 
time scurvy must be carefully watched for and in 
order to prevent this orange juice may well be ad- 
ministered earlier than usual. 



CHAPTER III. 
GROWTH AND DEVELOPMENT 

GROWTH and development are dependent on 
the quality and quantity of the food the in- 
fant receives and probably more on the former than 
on the latter. A steady increase in weight is a de- 
sirable and essential evidence of proper nutrition 
and yet one must not rely on this evidence alone. 
The birth weight of the average child is approxi- 
mately seven and one-quarter pounds, females 
slightly below this and males slightly above. At 
five months the average child doubles its birth 
weight and at twelve months the birth weight is 
almost trebled. At the end of the second year, 
the average child weighs twenty-six pounds and at 
the end of three years thirty-one pounds. It must 
be remembered that these are averages and must 
not be regarded as absolute figures. A child weigh- 
ing only six pounds at birth is well developed if it 
weighs eighteen pounds at the end of the first year, 
and a child weighing ten pounds at birth would be 
expected to weigh thirty pounds at the end of the 
first year. A child small at birth increases at a nor- 
mal rate for the first six months. It is apt to gain 
more rapidly than the child who was heavier, at 
birth, during the second six months and it is not 

27 



28 INI^ANT l^E^DING. 

infrequent to find a child small at birth weighing 
as much at the end of six months as a child of aver- 
age weight. Also, a child that is abnormally heavy 
at birth is not as apt to reach a treble weight at 
one year as is the average child. The average week- 
ly gain of a breast fed baby is larger during the 
first six months (6 oz.) than the second (4 oz.) 
and a breast fed baby uniformly maintains a heav- 
ier weekly average than the bottle fed baby. This 
does not apply, however, to infants who have had 
long, exhausting illness for in these cases the aver- 
age weekly gain is apt to be excessive for a while. 
Barring such cases as these a child on the bottle 
who gains excessively over the average is in danger 
of a general upset from the overtaxing of the di- 
gestion and I have repeatedly seen a disturbance 
of the digestion predicted by a sudden rapid gain 
in weight. This fact emphasizes the importance 
of occasionally checking the feedings by an estima- 
tion of the caloric values of food. 

The length of a child bears a more definite rela- 
tion to its age than does its weight. At birth, the 
average child measures 20^ inches in length, gains 
eight inches during the first year and 4 inches the 
second year. These figures are very nearly constant. 
A fat infant is much desired by the average moth- 
er, but fatness in an infant and proper nutritional 
development do not necessarily accompany each 
other. Especially is this true of infants fattened 
by means of certain proprietary foods which are 
rich in sugar and starch. It is in just such cases 



GROWTH AND DEVE^LOPMENT. 29 

as these that rickets and scurvy develop most fre- 
quently. Therefore, as stated, weight alone should 
not be our guide as to the state of nutrition, par- 
ticularly is this true in the case of artificially fed 
infants. 

Other points of observation are the time of clo- 
sure of the fontanels, delay in their closure being 
due most frequently to rickets, also to hydrocepha- 
lus, although the latter is not a nutritional disor- 
der. Cranio-tabes is also to be looked for as in- 
dicating both syphilis and rickets. The degree of 
firmness of the flesh of the infant is obvious to the 
practiced observer at the first examination and tells 
us much concerning the lack of proper food. The 
study of the head should furnish us the first warn- 
ing of approaching rickets and call for an immedi- 
ate change of diet. The attendant physician should 
be constantly on the watch for epiphyseal enlarge- 
ments and the development of rachitic rosary. The 
shape of the head also furnishes us a useful guide 
as to nutrition, as the early change in contour of 
the cranium should immediately put us on our 
guard, while localized sweating of the head means 
almost always the incipiency of rickets. It is as- 
tonishing how frequently the development of scurvy 
escapes the notice of the attending physician. 
Scurvy is essentially a nutritional disturbance in 
the artificially fed and usually arises during a pro- 
longed use of condensed milk or of those propri- 
etary foods which are not mixed with fresh cow's 
milk. I have never seen scurvy develop in the 



30 INFANT FEEDING. 

course of feeding on boiled milk though whenever 
this is used the attending physician should be con- 
stantly on his guard. If boiled milk is necessary 
for any prolonged period, it is wise to begin the 
use of orange juice early. Therefore, in consider- 
ing the proper amount of growth and development 
we should take into account increase in weight, 
average gain in length, degree of firmness of sub- 
cutaneous tissue, size of fontanels and the presence 
or absence of the signs of rickets or scurvy. 



CHAPTER IV. 

THE STOOLS IN INFANCY. 

By John Lovktt Morse, M.D. 

IT hardly seems necessary to emphasize the im- 
portance in relation to both diagnosis and treat- 
ment of the examination of the infant's stools in 
disturbances of digestion. It seems self-evident 
that the treatment cannot be carried out properly 
unless the cause of the disturbance is known, and 
in no other way can the cause be as accurately and 
as quickly determined as by the examination of the 
stools. The examination of the stools is, neverthe- 
less, unless I am much mistaken, often entirely neg- 
lected, or, if not neglected, carried out hastily and 
imperfectly. I am sure the stools would be exam- 
ined more often and more carefully if the impor- 
tance of the examination were thoroughly appreci- 
ated. 

The character of the stools depends primarily 
on the composition of the food and digestive power 
of the individual infant and the amount and rapidity 
of the absorption of the products of digestion, the 
latter being dependent, in turn, upon the rapidity 
of the passage of the intestinal contents through the 
intestinal canal. The character of the stools is also 
modified materially by the intestinal bacterial flora 
of the individual infant. The influence which this 

31 



32 INI^ANT FEEDING. 

flora has depends to a large extent on the digestive 
power and rapidity of absorption, as the bacteria 
have much more opportunity to act when the di- 
gestive powers are feeble and the absorption slow. 
The bacterial flora depends in a great measure, 
moreover, on the nature of the food. It is evident, 
therefore, that it is more difficult to draw conclu- 
sions as to the processes going on in the digestive 
tract from the examination of the stools than would 
at flrst appear. It is possible in most cases, how- 
ever, to determine whether any given food element 
is properly digested and assimilated or not, and in 
many diseased conditions to tell what element is 
at fault. Experience shows, moreover, that dimin- 
shing or withdrawing the element which is not be- 
ing digested has an immediate effect on the char- 
acter of the stools and upon the course of the dis- 
ease. 

The stools differ normally according as to 
whether the infant is taking human milk or cow's 
milk, and whether starches or other carbohydrates 
are added to the cow's milk. 

The Stools of Breast Fed Infants. — The breast 
fed infant has, during the first few weeks or months 
of life, three or four movements daily of the con- 
sistency of pea soup, of a peculiar golden-yellow 
color, with a slightly sour or aromatic odor, and 
with a slightly acid reaction. The number of stools 
diminishes later to two or three in the twenty-four 
hours and the consistency becomes more salve-like, 
the other characteristics remaining the same. The 



THE STOOLS IN INI^ANCY. 33 

golden color is due to bilirubin, which passes un- 
changed through the intestinal tract because of the 
rapidity of the passage, the relatively low proteid 
content of the milk and the low reducing power of 
the infant's intestine. The odor is due to a com- 
bination of lactic and fatty acids. The acid reac- 
tion is due to the relative excess of fat over pro- 
teid in the milk. 

It is not uncommon, even when babies are do- 
ing well on the breast, for them to have a large 
number of stools of diminished consistency and 
of a brownish color. In such instances, examina- 
tion of the breast milk usually shows that the pro- 
teids are high. It is also not unusual to find nu- 
merous soft fine curds and sometimes mucus in 
the stools of healthy breast fed babies. While such 
stools are undoubtedly abnormal, it is unwise to 
pay too much attention to them if the baby is gain- 
ing and seems well. The breast fed infant will of- 
ten go weeks or months without a normal stool and 
yet thrive perfectly, while if it had such stools while 
it was taking cow's milk it would not thrive and 
would show distinct evidences of malnutrition. It 
is, therefore, unwise to wean a baby simply because 
the stools are abnormal, if it is doing well in other 
ways. 

The Stools of Infants Fed on Cow's Milk.— In- 
fants that are thriving on cow's milk mixtures 
have, in my experience, fewer movements in the 
twenty-four hours than breast fed babies and the 
movements are of firmer consistency. Slight con- 



34 INFANT FE:EDING. 

stipation is not uncommon after the first few months 
and it is not of pathological significance. The color 
of the stools is a light yellow, probably because of 
the relatively larger amount of proteid, and because 
some of the bilirubin is converted into hydrobili- 
rubin. When the relative proportions of fat and 
proteids in the mixtures are approximately those 
of breast milk, the color and reaction of the stools 
are essentially the same as when the infant is tak- 
ing breast milk. When infants are given whole 
cow's milk or simple dilutions of cow's milk, so 
that the proteids are equal to or greater than the 
fat, the odor is slightly modified toward the fecal 
or cheesy because of the action of the bacteria on 
the casein. The reaction becomes alkaline for the 
same reason. 

Skim Milk Mixtures. — When infants are fed on 
skim milk or on mixtures very low in fat and high 
in proteids, the stools have a slightly brownish- 
yellow color, a slightly cheesy or foul odor, and 
a strongly alkaline reaction because of the longer 
stay of the casein in the intestines and the conse- 
quently greater opportunit}^ for bacterial action and 
for the change of bilirubin to hydrobilirubin. In 
some instances, the stools have a peculiar salve- 
like appearance like those from buttermilk. 

Whey and Whey Mixtures. — When infants are 
fed on whey or whey mixtures low in fat, the stools 
have essentially the same characteristics as those 
from skim milk, except that they are usually brown- 



the: STOOI.S IN INI^ANCY. 35 

er. Whey has a laxative action in many instances 
and sometimes has to be omitted for this reason. 

Starch Mixtures. — When starch is added to 
cow's milk mixtures, the color of the stools becomes 
more distinctly brownish and the reaction tends 
toward the acid. The odor is more aromatic. The 
character of the starch has, in my experience, but 
little effect on the number of movements, in spite 
of the common belief that barlej^ starch is consti- 
pating and oatmeal starch laxative. The action, 
if there is any, seems to vary with the individual 
infant. In this connection it must not be forgot- 
ten that most starch flours contain small brownish 
specks which are the remains of the husks. These 
specks pass through the gastro-intestinal tract un- 
affected and appear in the stools. 

Malt Sugar Mixtures. — The addition of malt 
sugar to cow's milk mixtures changes the color of 
the stools to a distinct brown, tends to make the 
reaction acid and to increase the acidity of the 
odor. Malt sugar usually has a laxative influence, 
but sometimes constipates. When malt sugar or 
the malted foods are given without milk the stools 
are dark brown, sticky, acrid in odor and acid in 
reaction. 

Buttermilk and Buttermilk Mixtures. — The 
stools of infants fed on buttermilk and buttermilk 
mixtures are of a peculiar, shiny, salve-like ap- 
pearance, grayish-brown in color, alkaline in reac- 
tion and have a very characteristic odor. 

Animal Food. — When beef juice or broth are 



36 INFANT I^EEDING. 

added to the infant's diet the color is changed to 
brown, while the odor becomes fecal and the reac- 
tion alkaline from the action of the bacteria on the 
proteids. 

The Starvation Stool. — The starvation stool is 
made up of bile, the intestinal secretions and bac- 
teria and resembles the meconium. It is usually 
small, sometimes constipated, sometimes loose, 
brownish or brownish-green in color and has, as 
a rule, a stale odor like that of starch or paste. In 
some cases it has the odor of acetic acid as the re- 
sult of the action of micro-organisms. 

Reaction of the Stools. — The reaction of the 
normal stool depends on the relation between the 
fat and the proteids in the food. When there is 
a relative excess of fat the reaction is acid; when 
there is a relative excess of proteid the reaction is 
alkaline, the reaction depending, in the one case, 
on the products of the decomposition of fat, in the 
other, on the composition of the decomposition of 
proteids. The carbohydrates have no effect on the 
reaction of the normal stool. When the carbohy- 
drates are in excess, or when there is fermentation 
of the carbohydrates as the result of bacterial ac- 
tion, the acidity of the stools is markedly increased. 
Stools which irritate the buttocks are invariably 
acid in reaction, and in most instances this exces- 
sive acidity is due to the decomposition of carbo- 
hydrates. Frothy stools are usually acid in reac- 
tion, and due to the same cause, but sometimes the 
frothiness is caused by gases formed during the 



THE STOOI.S IN INFANCY. 37 

decomposition of proteids. The reaction of the 
stools is, however, of comparatively little impor- 
tance from the clinical side. It is best tested by 
placing wet red or blue litmus paper on, not in, the 
stool. 

Color of Stools. — The normal variations in the 
color of stools according to the composition of the 
food have already been mentioned. Abnormalities 
in the color are very common. The color of the 
stool must not be judged from the outside, as it 
may change very rapidly from drying and exposure 
to the air. The stool must be broken up and 
smoothed out and the inside examined. 

Green. — The most common abnormal color is 
green. The shade of green may vary from a very 
delicate light grass-green to a dark spinach-green. 
In a general way, the darker the green the greater 
its significance. A very light grass-green color in 
a stool which is otherwise normal is of no prac- 
tical importance. The change from yellow to green 
after the stool is passed is not abnormal. The 
green color is, in the vast majority of cases, due to 
the change of bilirubin to biliverdin. There is much 
doubt as to the cause of this change. It is prob- 
able that it may be due to either excessive acidity 
or alkalinity of the intestinal contents or to^ the 
presence of some oxidizing ferment. The green 
color is not characteristic of any special type of dis- 
ease. In some instances it is due to the action of 
the bacillus pyocyaneus. If it is due to bacterial 
action, the addition of nitric acid decolorizes the 



38 INF^ANT FEEDING. 

Stool. If it is due to biliverdin, the action of nitric 
acid gives the characteristic colors of Gmelin's test. 

Gray, — The next most common abnormal color 
is gray. This is due, as a rule, to the absence of 
bile and the presence of some form of fat in the 
stool. It must be remembered, however, that there 
may be bile in the stool even when it is gray, the 
bile pigment being in the form of the colorless 
leucohydrobilirubin. It is never safe, therefore, to 
conclude there is no bile in the stool without a 
chemical examination. The easiest and most satis- 
factory test is that with corrosive sublimate. When 
the stools are gray at birth, or become so within 
a few days after birth, the lesion is usually a con- 
genital obliteration of the bile ducts. When the 
gray color appears later, and especially when it is 
associated with large amounts of mucus, the trouble 
is usually in the duodenum. 

White, — The white stools are due to the pres- 
ence of undigested fat in the form of soaps. These 
may be soft, looking much like curdled milk, or 
more often, hard and dry, resembling the stools 
of a dog which has been eating bones. 

Black. — The black stool, while in rare instances 
due to the presence of changed blood, is usually 
due to the action of some drug, ordinarily bismuth, 
sometimes iron. In this connection, it is well to 
remember that when there is no sulphuretted hy- 
drogen in the intestine bismuth may pass through 
the intestinal tract without changing the color. The 
administration of a grain or two of sulphur in the 



THE STOOIvS IN INFANCY. 39 

twenty-four hours will turn the stools black. 
Whether or not this is of any advantage is ques- 
tionable. 

Blue. — The stools are sometimes of a slaty-blue 
color. This color is due to some change in the bile 
pigments and is of no more significance than the 
green. 

It is very common to see a pink stain on the 
diapers about a stool which is otherwise normal 
or nearly so. This pink stain is of no especial sig- 
nificance and is due to some unknown change in 
the bile pigment. 

Abnormal Constituents. — Curds. — The most 
common abnormal constituents are curds. Judg- 
ing from the literature of the subject, there is a 
great deal of confusion as to the composition and 
significance of the curds in infants' stools. The 
matter is, however, a simple one. There are two 
kinds of curds, one primarily composed of casein, 
the other composed mainly of fat, mostly in the 
form of fatty acids and soaps. The small amount 
of fat in the casein curds and the small amount of 
proteid in the fat curds are merely incidents. The 
casein curds vary in size from that of a bean to 
that of a pecan nut. They are usually white, some- 
times yellow in color. They are firm and tough, 
cannot be broken up by pressure and sink in water. 
When placed in formalin they become as hard as 
rocks ; they are insoluble in ether. The fat curds 
are small, varying in size from that of a pin head 
to that of a small pea. They vary in color from 



40 INFANT I^^E:dING. 

white to yellow or green, according to the general 
color of the movements. They are easily broken 
up by pressure, and, when shaken up in water, tend 
to remain in suspension. They are soluble in ether 
to a considerable extent after acidification and are 
unaffected by formalin. 

Mucus. — Mucus can be detected in small 
amounts under the microscope in the majority of 
normal stools, and is almost invariably present in 
abnormal stools. It is never present macroscopical- 
ly in normal stools, but is very common in the ab- 
normal. It does not denote any special form of dis- 
ease, merely an excessive secretion of the mucous 
glands of the intestines from some cause. When 
thoroughly mixed throughout the stool it usually 
comes from the small intestine ; when in combina- 
tion with a clay-colored stool, from the duodenum; 
when on the outside of a constipated stool, from the 
rectum. Stools composed mainly or entirely of 
mucus and blood indicate either severe inflamma- 
tion of the colon or intussusception. Undigested 
starch is often mistaken for mucus. They can be 
distinguished by the addition of some preparation 
of iodine, which stains the starch blue, but does not 
affect the mucus. The suspected material should 
be taken off the diaper in order to avoid possible 
confusion from the presence of starch on the 
diaper. 

Blood. — Blood on the outside of a constipated 
stool indicates a crack in the anus. Blood mixed 
with mucus indicates either severe inflammation of 



THE STOOLS IN INF^ANCY. 41 

the large intestine or intussusception. Blood in in- 
fancy is seldom due to hemorrhoids. 

Pus. — Pus indicates severe inflammation of the 
large intestine. It is usually not present early in 
the disease, but appears later on. When the in- 
fants survive the acute stage it persists into con- 
valescence. Pus can be found with the microscope 
in nearly every case of inflammation of the colon, 
but it is of no special significance unless visible 
macroscopically. 

Membrane. — Membrane indicates very severe in- 
flammation of the large intestine and is rarely seen, 
the patients usually dying before membrane ap- 
pears in the stools. 

Other abnormal constituents are undigested 
masses of food, foreign bodies which may have been 
swallowed, and worms. 

Microscopic Examination of the Stools. — The 
macroscopic examination of the stools affords data 
sufficiently reliable for clinical work in the great 
majority of instances. It may, however, lead to 
erroneous conclusions, especially with regard to the 
amount of fat and undigested starch. Fatty and 
starchy stools sometimes appear perfectly normal 
macroscopically and microscopic examination alone 
will prevent mistakes. It is advisable, therefore, 
in all but the plainest cases to examine the stools 
microscopically as well as macroscopically. The 
microscopical examination of the stools is not a 
difficult procedure and can be carried out in ten 
minutes or less by any one accustomed to it. Con- 



42 INFANT FEEDING. 

trols of the microscopic examination by chemical 
examination of the stools have shown that it gives 
results sufficiently reliable for clinical purposes. A 
certain amount of experience is necessary, how- 
ever, in order to recognize the normal variations in 
the microscopic picture. The stools normally 
show a certain amount of fat in some form or other, 
but never show unchanged starch. The chief dif- 
ficulty in the microscopic examination is to learn to 
recognize the normal variations in the amount of 
fat. 

The feces, if hard, are first rubbed up with a 
little water. Otherwise they are thoroughly mixed, 
and three small portions placed on a slide. The 
first is crushed out very thin under the cover glass 
and examined in the fresh condition. In this por- 
tion any undigested tissues or pathological ele- 
ments, such as blood, pus, and eggs of parasites, 
can be diflferentiated. A preliminary estimation of 
the amount of neutral fat, fatty acids, soaps and 
starches may also be made. 

The second portion is stained with Lugol's so- 
lution (iodine 2, potassium iodide 4, distilled water 
100) and examined for starch. The starch gran- 
ules stain blue or violet. Certain microbes also 
stain blue. These, the so-called iodophilic bacteria, 
are associated with faulty carbohydrate digestion 
and, when found alone without other symptoms, 
are suggestive of an early disturbance in the di- 
gestion of the carbohydrates. Before concluding 
that undigested starch is present, all possibility of 



THE STOOIvS IN INFANCY. 43 

contamination with baby powders must be elimi- 
nated. 

The third portion is stained with a saturated al- 
coholic solution of Sudan iii. The neutral fat drops 
and fat acid crystals stain red. Soap crystals do 
not stain with Sudan iii. After this specimen is 
examined and the microscopic picture is clear, a 
drop of glacial acetic acid is allowed to run under 
the cover of the glass, is thoroughly mixed in and 
then heated until it begins to boil. This process 
turns the soap into neutral fat and fatty acid which 
v/ill appear as large stained drops and upon cool- 
ing crystallizes. They usually retain the red stain. 
Any increase in the amount of fat after the addi- 
tion of acetic acid indicates the presence of a cor- 
responding amount of soaps. If there are any fat 
drops visible after the addition of Sudan iii and be- 
fore the addition of acetic acid, another specimen 
should be stained with a dilute solution of carbol- 
fuchsin (carbolfuchsin sol. 1: water, 4 or 5). With 
this solution the neutral fat is not stained, while 
the fatty acids are stained a deep red and the soaps 
a dull rose-red. Without this stain it is impossible 
to distinguish neutral fat from fatty acids. An ex- 
cess of neutral fat indicates that the digestion of 
fat is not carried on normally; an excess of fatty 
acids and soaps, that the digestion is normal, but 
assimilation is abnormal. 

It is well to examine the specimen first with a 
low power objective and later with a No. 7 objec- 
tive in order to bring out the detailed structure. 



44 INFANT ^e:e:ding. 

Bacteriologic Examination of the Stools. — Our 

knowledge of the bacteriology of the disturbances 
of digestion and of the various inflammatory dis- 
eases of the intestine is so limited at present that 
no conclusions of clinical importance can be drawn 
from the microscopical examination of the stools, 
the only exception being, possibly, the presence of 
large numbers of iodophilic bacteria, which, as al- 
ready stated, point to the disturbance of the diges- 
tion of the carbohydrates. 

The Stools of Different Types of Indigestion. — 

It may be well, perhaps, to sum up the character- 
istics of the stools in some of the more marked 
types of indigestion. The stools of the various in- 
flammatory conditions are familiar to every one 
and hardly need further description. 

The Stools of Fat Indigestion. — Undigested fat 
may show itself in the stools in the form of small, 
soft curds, by giving a greasy, shiny appearance to 
the stools or by giving a gray or white color. The 
small curds are, of course, easily recognized. The 
presence of undigested fat may be shown roughly 
by rubbing some of the stool on a piece of smooth 
soft paper. If there is an excess of fat, the paper 
will have, when dry, the appearance of oiled pa- 
per. When there is an excess of neutral fat the 
stools are often of a creamy consistency. If the 
fat is largely in the form of soaps, the stools are 
usually clay-like or very dry and crumbly. The re- 
action is highly acid; the odor rancid, like that of 



THE STOOI.S IN INFANCY. 45 

butyric acid. Microscopically these stools show a 
large excess of fat in various forms. 

The Stools of Carbohydrate Indigestion. — The 
character of the stools of carbohydrate indigestion 
depends on whether the disturbance is in the di- 
gestion of starch alone without bacterial action or 
in the digestion of either or both starch and sugar 
with bacterial fermentation. When the disturb- 
ance is solely in the digestion of starch and bac- 
terial fermentation is not marked the stools are 
brown or golden yellow in color, and salve-like in 
consistency. They may, as already stated, appear 
macroscopically normal. In rare instances they are 
very dry and brittle. The reaction is acid. The 
odor is acid, the character of the odor depending 
on the form of acid present. The iodine test will 
often macroscopically show the presence of undi- 
gested starch. Microscopically these stools show 
undigested starch by the iodine test, and an ex- 
cess of iodophilic bacteria. When bacterial fer- 
mentation is added to the disturbance of digestion 
of either starch or sugar the stools are loose, green 
and frothy. The reaction is acid from the pres- 
ence of lactic, acetic and succinic acid. The odor 
is acid, the character of the odor depending on 
the form of the acid present. These stools often 
cause excoriation of the buttocks and genitals. 

The Stools of Proteid Indigestion. — The pres- 
ence of large tough curds in the stools is, of course, 
evidence of proteid, or rather casein indigestion. 
In general, however, the stools of proteid indiges- 



46 INFANT fe:i;ding. 

tion are loose, brownish in color, alkaline in reac- 
tion and with a foul odor, the odor in some in- 
stances being fecal, in others cheesy, in others a 
combination of the two. The stools of proteid in- 
digestion are more likely to show an excess of 
mucus both microscopically and macroscopically 
than are those of either pure fat or carbohydrate in- 
digestion. 

Mixed Forms of Indigestion. — Mixed types of 
stools as the result of mixed types of indigestion 
modified by bacterial fermentation and decompo- 
sition are far more common than the pure types 
alone and are often very difficult to interpret. 

Conclusions. — It seems safe to draw the follow- 
ing conclusions regarding the examination of stools 
in infancy. The stools in infancy are not examined 
as often as they should be. The examination of the 
stools gives information regarding the digestive 
processes which cannot be obtained in any other 
way. Without such examination, treatment is al- 
ways unscientific and often irrational. The macro- 
scopic examination of the stools affords informa- 
tion of the greatest importance, but in many in- 
stances will lead to error unless the microscopic 
examination is also made. The microscopic exam- 
ination is a simple one and requires but little time. 
The results obtained from it are, for practical pur- 
poses, as reliable as those obtained from the chem- 
ical examination. 



CHAPTER V. 
BREAST FEEDING 

VERY few factors enter more strikingly into the 
success or failure of infant feeding than a 
right start. This applies both to breast feeding and 
artificial feeding, though, of course, to a less extent 
in the former than the latter. 

For the first few days of the puerperium, as is 
well known, the mother's breast contains little or 
no milk. During this time the infant is not in need 
of food else nature would have provided food for 
it. The child sleeps almost constantly. Usually 
on the third day, sometimes on the fourth, and 
occasionally as early as the second day, the moth- 
er's milk begins to flow. This is the rule for primi- 
parae; in multiparse, it may be present on the third 
day, especially in those women who have nursed 
a previous child well up into the later months of 
pregnancy. This makes no particular difference in 
the nursing of the new^-born, though it is apt to 
give the mother trouble. 

It is customary to begin children on six hour 
intervals for the first day or two at the breast and 
then shorten these periods to two or two and one- 
half hours. In referring to the intervals of feed- 
ing, it is well to count from the beginning of one 
feeding to the beginning of the next feeding. This 

47 



48 INFANT FE:EDING. 

question of the interval of feeding has been much 
discussed of late and to my mind entirely needless- 
ly. There are three criteria by which the inter- 
val is to be determined, namely, the vigor of the 
child, its capacity and the quantity of the moth- 
er's milk, this virtually resolves into the question 
of supply and demand. I do not think it is proper 
to follow fixed rules as is frequently done, in de- 
termining either the interval or the quantity of each 
feeding at the various ages. In the light of re- 
cent investigation through the experiments of Pisek 
and LeWald and others working with the serial 
radiographs it is found that children are as dis- 
tinctly individual as to their stomach capacity and 
the time the stomach requires to empty itself as 
they are in other respects. For example, these ex- 
perimenters have demonstrated the fact that chil- 
dren vary as to their stomach capacity as much as 
one or two ounces for a child of the same age and 
weight. The time required for the stomach to 
empty itself has also been proven to vary as much 
as the capacity, hence, generally speaking, the child 
itself must be our guide in both of these matters. 
I seldom feed a child oftener than every two and 
one-half hours, nor do I follow the other custom 
of four hour intervals as advocated so strongly of 
late unless I find a combination of a strong, lusty 
infant and a mother with an unusual supply of 
milk, the child possessing at the same time a ca- 
pacity which will tide it over with comfort for that 
length of time. 



BREJAST FEEDING. 49 

Generally speaking, the child should be aroused 
at definite intervals rather than be allowed to sleep 
over unusual periods, for if too long an interval, 
under these conditions, is allowed to elapse, not 
only will the child probably overcrowd its stomach 
thereby causing regurgitation and subsequent indi- 
gestion, but also the mother is subjected to an un- 
necessary amount of discomfort from an overfull 
breast. Regular intervals of feeding are also nec- 
essary to maintain an even and steady flow of milk 
in the mother's breast. Within reasonable limits, 
therefore, with a healthy nursing baby and a moth- 
er who requires no particular amount of watching, 
the nursings will usually take care of themselves, 
the intervals being relatively shorter during the 
early part of infancy and gradually lengthening to 
the natural time of weaning. For the first three 
months, the baby usually nurses once between ten 
p. m. and six a. m., after this time no nursing is 
necessary between these hours. The question of 
the mother's food during the period of lactation 
has received an unnecessary amount of attention ; 
good, wholesome, plain food and a sufficient quan- 
tity is all that is necessary. Since the mother's milk 
is primarily a secretion and only secondarily an 
excretion, food can influence the milk only in so 
far as it influences the general condition of the 
mother's nutrition. Whatever food is given, there- 
fore, should be directed toward the mother's gen- 
eral welfare and not chosen with any specific idea 
of increasing the supply of milk. 



50 'infant FE;i:DING. 

Overfeeding on the part of the mother is apt 
to cause a milk too rich in fats and, to a less ex- 
tent, in proteids, while lack of proper and well- 
regulated exercise will almost invariably produce 
a proteid indigestion, with colic, in the infant. As 
a rule, when an infant is suffering from either fat 
or proteid indigestion, it is manifested by the ap- 
pearance of fat or casein curds in the stools, with 
colic, and it is best treated through moderate exercise 
of the mother. 

Perhaps the most potent influence in milk pro- 
duction is the state of the mother's mind; a quiet, 
peaceful mind, free from undue worry, goes a long 
way toward the production of a sufficient supply of 
milk. On the other hand, constant worry, or a 
sudden mental shock is apt to give either a very 
poor grade of milk or a complete cessation of the 
flow. The best milk producer that I know of is 
the mouth of an infant. So strikingly is this the 
case that there are many instances of mothers nurs- 
ing several infants at the same time. In fact, more 
than one case is on record of one woman nurs- 
ing as many as five infants. I do not believe that 
any drugs have ever been proven of value in in- 
creasing the flow of milk, especially is this true of 
alcoholic and malt preparations. 

We hope for something definite to develop 
through the use of the products of internal secre- 
tions of normal glands. Constipation in the moth- 
er is a constant source of disturbed lactation. This 



BREAST P^KEDING. 51 

constipation is far better regulated by diet and ex- 
ercise than it is by drugs. 

There are a few contra-indications to maternal 
nursing. Recent observers have demonstrated the 
fact that toxemia of pregnancy furnishes a strik- 
ing contra-indication to nursing and wherever the 
mother has had a marked albuminuria with or with- 
out convulsions, the child should not be put to the 
breast until all traces of albumin have disappeared 
and then only with the utmost care and supervi- 
sion. In the meantime, the mother's breast should 
be stimulated to secrete by means of a breast pump 
so that the child may yet receive its natural food. 
Open tuberculosis is, of course, a contra-indication 
which needs no argument ; insanity also should lead 
us to interrupt the nursing, while sudden emotion 
such as fright and the like may furnish a contra- 
indication. Other causes of the sudden interrup- 
tion of the secretion may arise temporarily, requir- 
ing the substitution of the bottle for short periods. 
The return to the breast may be made when such 
causes are removed. 

When a child is not gaining in weight and 
strength at the breast, the most careful observa- 
tions should be made. The only way to determine 
whether a sufficient quantity of milk is being sup- 
plied is by frequently weighing the infant before 
and after nursing, in this way we may determine 
the amount supplied at each feeding. 

An absolutely correct estimate of the quality of 
mother's milk can be secured only through an ex- 



52 INFANT E^EEDING. 

tensive and complete analysis which requires the 
service of an expert chemist. The percentage of 
fat can be roughly estimated by means of the Holt 
instrument or the Milchpriifer (pioskop). In es- 
timating breast milk it is well to bear in mind one 
fact, and that is that the milk during the first few 
moments of nursing is the poorest, the richest milk 
coming at the end of the nursing, half way of the 
feeding giving us the best average. 

Wet nurses are not as much employed in Amer- 
ica as in other countries. This fact is to be re- 
gretted since there are many infants who are either 
born weak or have become so through illness, espe- 
cially of the gastrointestinal type, which can be 
saved in no other way than through wet nursing, 
when their mothers have not a sufficient supply. 
All the rules governing maternal feeding apply 
equally to the wet nursing, with the further provi- 
sion that all wet nurses should be proven to be 
free from tuberculosis, syphilis and gonorrhea and 
with the still further provision that the wet nurse 
can also nurse her own baby to whom she owes 
her first duty. 

Mixed feeding of breast and bottle must often 
of necessity be resorted to. The same general rules 
suggested above apply in this case as applies to 
the maternal nursing alone and to artificial feed- 
ing (subsequent chapter) with the following excep- 
tions — that it is well to determine the capacity of 
the child's stomach and the interval of feeding nec- 
essary by giving several successive bottle feedings, 



BRKAST I^e:EDING. 53 

then to determine the amount of milk the mother 
supplies at each nursing by weighing the baby sev- 
eral times before and after feeding. Whether we 
use complementary or supplementary feedings will 
depend on the indications. In supplementary feed- 
ing we make up the deficiency at each maternal 
nursing by a bottle feeding; in complementary 
feeding, we alternate the two. The best rule to 
follow here is that if the quantity of the mother's 
milk is deficient, we put the baby to the breast at 
the regular hours and then supplement with the 
bottle; if the quality of the mother's milk is de- 
ficient, we use the complementary feedings, thus 
allowing the mother to rest for a longer period. 
In these cases we should always bear in mind two 
facts; the baby's mouth is the best stimulus to the 
mother's breast and that we should hold on to 
mother's milk if it is only one nursing a day as 
long as the child needs constant attention. 



CHAPTER VI. 

THE HANDLING OF A NORMAL BABY ON 
THE BOTTLE 

WHEN we have a strictly normal baby to deal 
with, one that is well developed and nour- 
ished, whether this child is started on the bottle at 
birth or later, the problem before us is compara- 
tively simple. This is the simplest of all infant 
feeding problems, although, in the strictest sense 
of the word, none is simple. 

In a somewhat extended experience in the feed- 
ing of infants, I have yet to see one which could 
not take some modification of cow's milk. The 
term ''adaptation" used by Kerley is decidedly the 
best term, since infant feeding consists essentially 
in adapting the proportions of the various elements 
in cow's milk to the digestive powers of the infant. 
We must bear in mind as a guide the percentages 
of the various elements as contained in mother's 
milk and cow's milk. An average of mother's mJlk 
contains 3.5 per cent fat, 7 per cent sugar, and 1.50 
per cent proteid ; while cow's milk contains 4 per 
cent fat, 4.5 per cent sugar and 3.2 per cent pro- 
teid. It will be seen at a glance that the percent- 
age of fat in cow's milk is slightly above that of 
the human milk; sugar 2.5 per cent lower than the 

54 



HANDLING OF NORMAL BABY ON BOTTLE). 55 

sugar of human milk while the proteid of cow's 
milk is nearly 2.5 times as great as that of mother's 
milk. 

As stated, the modifying of cow's milk so as to 
conform even exactly to human milk does not form 
a suitable adaptation to the infant's digestion and 
it is essential to modify it still further. It would 
be a hazardous procedure to place a young infant 
on a modification of cow's milk which contained 
3.5 per cent of fat (the percentage contained in 
mother's milk), also even 1.5 per cent of proteid of 
cow's milk is entirely too strong to begin feeding an 
infant. 

Another important fact to bear in mind is that 
mother's milk varies very slightly during the whole 
period of lactation and even the quantity of moth- 
er's milk varies within comparatively narrow lim- 
its, hence, on a more or less fixed proportion of 
quality and quantity an infant at the breast thrives 
over a period of from eight to twelve months. 

A striking feature of artificial feeding is that 
infants require a gradually increasing amount of 
modified milk both as to the proportion of ingredi- 
ents and as to total quantity. This fact alone 
proves to us the vastly different requirements of the 
infant when fed on the breast and on cow's milk 
and reminds us at once of the absolute necessity 
of gradually adapting the infant's digestion to the 
more difficult cow's milk. To any one doing a 
considerable amount of consultation work among 
infants one fact is apparent and that is that the 



56 INP^ANT I^EEDING. 

overtaxing of the infant's digestion by too large 
proportions of elements in cow's milk is much 
more frequent than the weakening of the diges- 
tion by a protracted feeding of too small propor- 
tions, although the latter class of cases does arise. 
Our main reliance must be comparatively weak 
mixtures to begin with, increasing them gradually 
until the digestion is equal to the task put upon it; 
in other words, the infant must be assisted in ac- 
quiring a tolerance for each element. 

When we deal with percentages, we are, of 
course, using approximate quantities. The milk 
from one herd will differ from the milk of an- 
other herd in the percentages of fat and proteid, 
the sugar usually being constant. At the same time, 
unless we are dealing with a certified milk which 
is certified even to the extent of the percentage of 
the various elements, certainly at least that of the 
fat, we may assume that cow's milk contains the 
percentage stated above and this is near enough for 
working purposes. 

The expressing of feeding in terms of percent- 
ages, therefore, calls for only approximation to ac- 
curacy, but is thoroughly useful to keep us gener- 
ally informed as to the quantity of each ingredient 
prescribed for the infant. In this way as in no 
other we may reduce the fat and increase the pro- 
teid even as much as .25 per cent at will and with 
comparative ease. Infants vary considerably in 
their ability to digest the fat content of cow's milk. 
In healthy infants it is rarely necessary to start 



HANDLING 01^ NORMAI, BABY ON BOTTI,!). 57 

with less than one per cent even during the first 
two weeks of life. Some authorities are accus- 
tomed to give the new-born infant as high as 2 per 
cent of fat. I have found this, generally, unwise and 
rarely risk more than 1 per cent. The fat is grad- 
ually increased as necessity and indication require 
and I think it a safe rule never to give beyond 4 
per cent, and in my practice I rarely exceed 3 per 
cent even towards the end of the first year. 

The variations and capability of digesting sugar 
are second only to those of fat, a safe rule being 
to range from 4 to 7 per cent. I rarely use less 
than 5 per cent even in young infants and prac- 
tically never exceed 7 per cent. I am quite aware 
of the fact that some infants acquire an enormous 
tolerance for sugar. This is frequently demon- 
strated to me when I see infants fed for long periods 
of time on condensed milk mixtures unusually high 
in sugar and those fed on proprietary foods espe- 
ially those rich in malt sugar. But, as I have 
pointed out before, when an intolerance for sugar 
is once established, it is one of the most diffiicult 
of the feeding problems to overcome, hence, it will 
be safer to use the range indicated above. 

The proteid of cow's milk undoubtedly gives us 
the least amount of trouble, intolerance usually be- 
ing confined to those cases presenting putrefac- 
tive manifestations. In instances of the large casein 
curds in the stools, the proteid content must be 
kept well within reasonable limits and in a nor- 



58 INI^ANT FEEDING. 

mal infant I rarely exceed 2 per cent proteid and 
practically never go beyond 2.5 per cent. 

When whole milk mixtures are substituted of 
course the percentage will more rapidly approxi- 
mate that found in cow's milk, but in my own ex- 
perience, few infants under 13 or 14 months are 
capable of handling whole cow's milk. 

The first formula given any child with which 
we are not thoroughly familiar is inevitably an ex- 
periment, and yet if we secure a careful history of 
previous feedings, the gain in weight or otherwise 
and after an examination of the stools, we should 
be able to approximate quite nearly the require- 
ments of the individual infant. This is especially 
true if we take the time to calculate the caloric 
needs of the infant and check this up after the for- 
mula has been worked out. 

The following tables furnish us with a theoreti- 
cal basis for our guidance in feeding normal healthy 
babies: 





Percent- 


Percent- 


Percent- 


Age 


age OF 


age OF 


age OF 




Fat 


Sugar 


Proteid 


Premature 


. \ .50 
( 1.00 


4.00 
4.00 


.25 




.25 


First week 


j 1.00 
/ 1.50 


5.00 
5.00 


.25 
.50 


Second week 


i 1.50 
\ 2.00 


5.00 
5.00 


.50 

.75 


Third week 


(2.00 
* * ( 2.00 


5.00 
6.00 


.75 
1.00 


First to second month. 


( 2.00 
( 3.00 


6.00 
6.00 


1.00 
1.00 



Percent- 


Percent- 


age OF 


age OF 


Sugar 


Proteid 


6.00 


1.25 


6.00 


1.50 


7.00 


1.75 


7.00 


1.75 


7.00 


1.75 


7.00 


2.00 


7.00 


2.00 


6.00 


2.00 


6.00 


2.50 


5.00 


3.00 


4.50 


3.20 



HANDLING 01^ NORMAI, BABY ON BOTTLE. 59 



Percent- 
Age AGE of 
Fat 

Third month 3.00 

Fourth month 3.00 

Fifth month 3.25 

Sixth month 3.50 

Seventh month 3.50 

Eighth month 3.50 

Ninth month 4.00 

Tenth month 4.00 

Eleventh month 4.00 

Twelfth month 4.00 

Thirteenth month 4.00 



It must be borne in mind that this is merely a 
suggestive table for average babies and that weight 
and general nutrition must guide us rather than 
age, since a delicate infant at six months may only 
be able to take a formula which is intended for a 
three or four months old baby; on the contrary, 
a lusty baby at four months may require a formula 
which is intended for a six months' infant. Under 
such circumstances a check by means of calories is 
advisable. 

It is with great hesitancy that I give a schedule 
of quantities for feeding at all, since I have em- 
phasized the fact that the individual child is a law 
unto himself in this particular more than any other 
and that variations are very great between infants 
of the same age and weight and yet it is useful 
to have some safe guide to follow when beginning 



60 INFANT F£:e;ding. 

a child on the bottle. With this clearly understood, 
I venture to give the following table : 

Agh Oz. per Feeding 

Premature J/^ to 1 

First week 1 " 2 

Second week 1^ " 2^ 

Third week 2 " 3 

First to second month 2^ " 4^ 

Third month 3 " 5 

Fourth month 3 " 5j4 

Fifth month 3>^ " 6 

Sixth month 4^ " 6;^ 

Seventh month 5 " 7 

Eighth month 5>^ " 7 

Ninth month 6 " ly^ 

Tenth month 6j4 " 8 

Eleventh month dVz '' 9 

Twelfth month 7 " 9 

Thirteenth month 7 " 10 

We have already considered the question of in- 
terval of feeding, but this is an important subject and 
can bear the second reference. It is rarely neces- 
sary to begin any infant on two hour intervals of 
feeding; two and a half hours, even among very 
young infants unless they are exceedingly delicate, 
is frequent enough. Perhaps the most convenient 
feeding interval is three hours; this is especially 
true in institutions where large numbers of babies 
are handled and consideration must be had for the 
time of the attendants. However, in private prac- 
tice we may vary from two and a half hours to four 
according to the child's appetite and general di- 
gestive capacity. This, as well as the quantity of 
each feeding, must be determined largely by the 



HANDIJNG OF NORMAI, BABY ON B0TTI,P). 61 

individual infant and I do not believe that wt can 
lay down any rule on this subject. 

A weekly record of the child's weight should 
be kept and a safe average maintained. The at- 
tending physician should always inspect the stools 
himself and not trust to the statement made by 
the mother. An examination based on the observa- 
tions made in the chapter on infant stools is ab- 
solutely necessary in the feeding of all infants. 

All artificially fed infants should be under the 
constant observation of a physician. Weekly or bi- 
weekly reports should be made in the case of those 
doing well and of course oftener when necessary. 
A mother or nurse should never increase the 
strength of a formula without the advice of the 
physician. Those in charge of infants should have 
explained to them certain symptoms which re- 
quire immediate reduction in certain food elements 
so that if the physician is not available this may 
be done, but as a rule there is ample time. 

In increasing the elements week by week or 
whenever necessary, it is well to increase the pro- 
teid one period and the fat the next, inspecting the 
stools from time to time to satisfy ourselves that 
the element is being well digested. It is just as 
important to bear in mind the rule which I follow 
for sick infants in feeding the healthy — first, symp- 
tom free; second, hungry; third, increase in 
weight. Our first aim should be to keep or make 
the baby free from such symptoms as regurgita- 
tion, vomiting, diarrhea, constipation and colic. 



62 INi^ANT FEE:dING. 

When this has been accomplished keep the child 
on that particular formula until it is hungry and 
then and then only may we safely look to an in- 
crease in weight. 

One symptom is frequently very troublesome 
and hard to control — constipation. It is undoubted- 
ly due to a disproportion in the food elements, and, 
as a rule, is readily corrected by a readjustment of 
these elements. The fat is more frequently the 
cause and at times it is necessary to reduce the 
fat to a very small percentage or even to eliminate 
it entirely for a while and gradually increase until 
the digestion is improved, on account of a grad- 
ually acquired tolerance. It is necessary in these 
cases to check the food elements by calculating the 
calories so that the infant may secure a sufficient 
ration. One very frequent cause of habitual con- 
stipation is the constant use of enemas and sup- 
positories or soap sticks. By the use of these, ar- 
tificial stimulation becomes the rule, the bowel re- 
lying on this before acting. When the food dis- 
turbance cannot be readily adjusted, milk of mag- 
nesia should be our main reliance. This is best 
administered by giving the dose required for a 
single purgation in the total twenty-four hour mix- 
ture. It will thus be equally divided into small 
doses in each bottle. Quite recently I have had 
very good success with white mineral oil (liquid 
paraffin). Regularity of habits of feeding and 
bowels is essential to success and no detail or symp- 
tom should be considered too small for the con- 
sideration of the physician. 



CHAPTER VII. 
THE CARE OF THE PREMATURE INFANT 

THE care of the premature infant, so far as the 
life of the infant is concerned, is one of the 
most hazardous risks in the whole of medicine. 
Under ordinary circumstances the mortality is ex- 
ceedingly high and the success or failure in the 
rearing of such infants is in proportion to the 
amount of prematurity. In other words, a child 
from two weeks to a month premature and which 
is quite well developed for this age, stands a very 
reasonable chance of being reared and the further 
we get away from full term development, the less 
chance we have of success. 

The three main indications in handling the pre- 
mature infant are ''the maintaining of normal heat; 
the nourishing of the infant; the prevention of in- 
fection." All newly-born infants have the heat 
regulating center poorly developed, hence, even 
with normal infants it is unwise to expose them to 
sudden changes of temperature. If this is impor- 
tant in the case of the full term child, it is many 
times more important for the premature, therefore, 
we should not bathe the premature infant at all 
at first. It should be oiled (olive oil) and this oil 
reapplied not oftener than every other day until 
the infant becomes as lusty as a full term child. 

63 
\ 



64 INF^ANT F^E^DING. 

The ordinary clothing of an infant should not be 
used at all ; in this stage we may wrap the child 
in absorbent wool which has been quilted, or in 
the so-called premature infant's gown. Whatever 
wrapping is employed should include the head, 
only the face being left open, and instead of the 
usual napkin, we put a pad of absorbent cotton 
to receive the discharges and this alone should be 
changed with regularity. The question of incuba- 
tors is one that is much mooted and outside of well 
regulated institutions with nurses trained especial- 
ly in the care of this class of infants they are not 
successful. As most of our work deals with the 
infant in the home, we use a basket or bassinet 
which has been well padded at the bottom and on 
the sides. The infant is placed in this and not re- 
moved at all even for its feedings. The heat may 
be maintained by the use of hot water bottles or 
bags not put close enough to the infant to burn 
it, or by the use of the electric pad attached to the 
ordinary electric light socket which may be placed 
underneath the infant sufficiently covered by blank- 
ets or cotton to protect it. I am told that this oc- 
casionally gets out of order and consequently must^ 
be carefully watched and kept from burning the 
infant. The infant's temperature must be main- 
tained at from 98 to 99 degrees as nearly as pos- 
sible. To do this we resort to the use of two ther- 
mometers, the ordinary household thermometer 
which is placed lying on the child's clothing and be- 
low the bed covering and should register some- 




1 



be 







''~^^k:'-i:->&-msS^^^A . 




^p^^^^fe 



CARE OF THE PREMATURE INFANT. 65 

where between 85 and 95, depending on the tem- 
perature of the child's body which must be meas- 
ured by means of a rectal thermometer several 
times a day for the early period of these premature 
existences. A temperature of 100 means that the 
child is getting too much external heat; a tempera- 
ture of 97 that it is getting too little heat. As a 
rule, these infants can be reared, so far as the heat 
is concerned, as successfully in this way as they 
can in an incubator. 

The atmosphere which they breathe should not 
be as hot as that usually considered necessary, 72 
degrees should be the hottest and the air of the 
room should be changed frequently to insure fresh- 
ness. 

The second indication, that of nourishment, is 
best met through breast milk. The milk of the 
child's mother is rarely available during the time 
of prematurity because it is not produced at this 
early stage, consequently, especially in the very 
young premature infant, the milk of a wet nurse 
is absolutely essential. It is rare, however, that we 
find a premature infant that can nurse from the 
breast or bottle so the wet nurse must have her 
breast pumped at regular intervals to secure this 
milk. She should be nursed at the same time by 
her own infant to secure a steady flow of the se- 
cretion, otherwise the milk will dry up quite rap- 
idly. It is rare that we find a premature infant 
that can take even mother's milk whole, conse- 
quently they must be fed a dilution of the breast 



66 INI^ANT I^EDDING. 

milk of about equal parts with a five per cent sugar 
solution. It may be necessary to give this by 
means of a medicine dropper or Breck feeder, or 
in the very weak, by means of the stomach tube 
which is passed through the nose or mouth of the 
infant into the stomach while it is lying in the 
crib. Whichever method is necessary, the child 
should never be removed from its basket for any 
purpose whatever except for the periodical oiling. 
This oiling should be done as quickly as possible 
and in a room whose temperature is approximately 
90 degrees F. 

The amount which the baby can take at each 
feeding depends entirely on the baby, from one- 
half to one ounce is the rule and from one and a 
half to two hours should be the interval. 

When breast milk is no longer necessary we 
resort to the usual modifications of cow's milk 
commencing with fat .50 to 1, sugar 4.50 to 5, pro- 
teid .75 to 1, and gradually working up in strength 
as the child's ability to assimilate is developed. 

The third indication — prevention of infection — 
is an exceedingly important one. Three avenues 
of infection are most usual in these cases; the 
mouth, the lungs and the umbilicus. The mouth 
should be kept as clean as possible without irritat- 
ing the mucous membrane. To accomplish this, the 
utmost gentleness in handling is absolutely neces- 
sary; nor is too frequent bathing of the mouth ad- 
visable, for through this means we may cause vom- 
iting through irritation of the throat. Pneumonia 




0—4 




Fig-. 3.— The Breck Feeder. 



care: OF' THE PREMATURE INFANT. 67 

is exceedingly common in these cases, to prevent 
which, a free flow of fresh air in the room constant- 
ly is absolutely necessary even while maintaining 
the bodily heat in the basket. The umbilicus needs 
only the care which is given any new-born baby, 
but if infection gains entrance, we have practically 
a hopeless task before us in attempting to save the 
child. 

The question of weight in these infants is even 
more important than under other conditions. The 
weighing may be done very quickly at the time of 
the oiling in a warm room and may be done with 
the child dressed in its premature gown making a de- 
duction for the weight of the gown, although this 
method is exceedingly inaccurate. 



CHAPTER VIII. 

DIGESTIVE DISTURBANCES OF THE 
BREAST FED INFANT 

BOTH nutritional and digestive disturbances are 
comparatively infrequent in breast fed chil- 
dren, or at least, are so slight or so transient that 
the physician is rarely called to attend them since 
they usually escape notice or are deemed of insuf- 
ficient importance to require his services, and just 
here lies the real danger because not infrequently 
such damage is done that when the physician is 
called he has difficulty in correcting it. 

Loss of weight or stationary weight in the nurs- 
ing child, in my opinion, is the result of insuffi- 
cient quantity of mother's milk and but rarely the 
result of impaired quality of the milk. Unless the 
infant is weighed at stated intervals, the station- 
ary or falling weight may not be noticed for some 
time, with the result that the infant not only loses 
weight which is difficult for him to make up, but 
also the digestive power is lowered because he has 
not had enough food to stimulate it. Under these 
circumstances when the change to artificial feed- 
ing is made there is difficulty in adjusting the food 
to the digestion. It is far better, therefore, when 
it is certain that the mother is not giving a suf- 
ficient quantity to make use of the bottle before 

68 



DIGESTIVE DISTURBANCES OF BREAST :^ED INI^ANT. 69 

the child has begun to be marantic. When the 
bottle appears to be unavoidable, we should en- 
deavor to find out how much milk the mother is 
giving by weighing the baby before and after each 
nursing; this should be done several times a day 
for several days and then, in the majority of cases, 
a bottle containing a sufficient amount to make 
up the deficiency in the quantity of the breast milk 
should be given to supplement each breast feed- 
ing. In this way the mother's breast has the ad- 
vantage of the constant stimulation from the baby's 
mouth and consequently the possibility is main- 
tained of increasing her supply, but when this fails 
and the mother's milk shows a steady decrease, 
resort must be made to complementary feedings. 
At first we may substitute perhaps two bottles of 
full feeding for two maternal nursings and the ef- 
fort must be made constantly to keep up the breast 
as long as possible, even if only a partial breast 
feeding can be given two or three times a day, be- 
cause the infant certainly takes cow's milk far bet- 
ter in the presence of small quantities of breast milk 
than with none at all. 

In weighing the baby to determine either the 
amount of mother's milk furnished or to find the 
net weight, the baby should always be weighed nude. 

The infant's stools furnish us a very valuable 
guide in determining the nature of the nourish- 
ment. They frequently acquire the ^^starvation 
stool" character, which is brownish or greenish and 
very small and thin, frequently so small as to make 



70 INB^ANT i^EKDING. 

merely a stain on the napkin. This stool resem- 
bles very closely the ''starvation stooF' of the arti- 
ficially fed. 

Inanition fever has been described by Holt as 
coming on about the end of the first week of life. 
After excluding such causes of fever as infectious 
and the toxemia of the new born and assuring our- 
selves that the mother is giving an insufficient sup- 
ply of milk, feeding the infant a solution of milk 
sugar or a weak solution of cow's milk mixture 
should cause this fever to disappear. I have seldom 
seen this condition myself and its frequency I can- 
not vouch for. 

The toxemia of the new born has been de- 
scribed by Morse. This usually develops before 
the termination of the meconium stools and is a 
true infection, presumably arising from careless or 
unclean handling of the mouth through which 
channel it is supposed to enter. 

Its treatment consists in withdrawing all milk 
products, giving a purgative, preferably of milk of 
magnesia and substituting a five per cent solution 
of milk sugar until the fever has subsided when a 
return to the original feeding can be made almost 
immediately. 

Colic in the breast fed is more common than 
is usually supposed. This symptom undoubtedly 
arises from some form of dyspepsia and when met 
with is very frequently a troublesome condition. 
The most frequent manifestation is pain with in- 
termittent or constant crying sometimes bearing 



DIGESTIVE DISTURBANCES OF BREAST I^ED INFANT. 71 

a definite relation to the feeding and at other times 
no relation whatever to it. It is frequently re- 
lieved by nursing only to come on with renewed 
vigor a short while afterwards. In the majority 
of instances it is accompanied by the formation and 
expulsion of gas both from the stomach and bowel. 
If from the bowel, a simple suds enema will usual- 
ly relieve the individual attack, but carminatives 
such as asafetida, peppermint and soda, and fen- 
nel and catnip may be wisely resorted to. In han- 
dling these cases thus it is obvious that we are 
merely treating symptoms and not the real under- 
lying cause. Colic most frequently occurs in well 
nourished infants. 

Vomiting may occur as an accompaniment to 
or quite independent of colic. In the vast major- 
ity of instances whether in the breast fed or bottle 
fed vomiting has its origin in one of four causes: 
too much feeding, too frequent feeding, too high 
percentage of fat, too much handling. I believe 
that the frequent and unnecessary habit of jolting 
infants is responsible for the largest percentage of 
vomiting. Cases in which handling is responsible 
should be easily corrected by a little patience and 
persistence on the part of those having the care 
of the infant. Where too large quantities or too 
frequent feedings are the cause, the cutting down 
of the time of nursing or the lengthening of the 
intervals or both should correct this. Even in 
healthy nursing mothers I find indigestion of this 
type can be relieved by commencing with very 



72 INI^ANT I^EE;DING. 

short feeding, using a clock as a guide and not 
guess work. I not infrequently reduce the length 
of feeding to one minute gradually increasing to 
two, three, four, five, up to a normal fifteen or 
twenty minute feeding, and in these cases the 
longer interval between feedings is sometimes ex- 
ceedingly helpful. Where the mother's milk is too 
rich in fat or proteid we sometimes have great dif- 
ficulty. I do not approve of dieting a nursing 
mother too much, though very rich or highly sea- 
soned foods must be interdicted. When the fat is 
at fault as indicated by the vomiting of very sour 
food soon after nursing and almost always by the 
presence of the small white fat curds in the stools, 
it usually becomes necessary to dilute the mother's 
milk. This may be done by feeding a little boiled 
water just before or after nursing. I think the first 
better as the baby is more apt to take it when 
hungry than after a partial feeding. Moderate out- 
door exercise on the part of the mother will re- 
lieve this condition more promptly than anything 
else. This is especially true where the proteids 
in the mother's milk are at fault. In these instances 
the stools may or may not contain casein curds (the 
large hard brown curds resembling almonds). The 
nursing of an infant at regular intervals cannot 
be too strongly emphasized. The habit of nurs- 
ing a child whenever it cries is pernicious in the 
extreme because as a rule these children are crying 
not from hunger but from indigestion caused by 
too frequent feedings. A steady gain in weight 



DIGESTIVE) DISTURBANCES 01^ BREAST FED INI^ANT. 73 

with freedom from S3^mptoms as colic and the like 
in the breast fed infant should satisfy us of its 
proper nutrition. In addition to these disturb- 
ances, breast fed babies are subject to the acute 
gastric and intestinal indigestions described in the 
next chapter but very rarely v^ith the same de- 
gree of severity. Their handling is essentially the 
same as that given under ''artificial feeding" ex- 
cept that we are rarely compelled to- withhold food 
for so long a time and of course we dilute the 
food in the breast fed infant by giving some boiled 
water before each nursing, otherwise, their han- 
dling is practically the same. 



CHAPTER IX. 

DIGESTIVE DISTURBANCES IN ARTI- 
FICIALLY FED INFANTS 

THE limitations of a book of this nature are 
such as to admit of the merest suggestions 
of these conditions. As has already been stated, 
the proteid in cow's milk was, for a long time, 
blamed for most if not all of the digestive dis- 
turbances in the artificially fed infant. After a 
while opinion changed and fat bore the weight of 
the burden, then sugar came in for its share of 
the blame as the cause of the trouble and lastly 
the salts have been considered. Investigation 
which placed the blame on a single element served 
a very definite purpose — that of proving that any 
element may cause digestive disturbances and that 
a disturbance which is caused primarily by an ex- 
cess of any one element beyond the capabilities of 
that individual infant, also ultimately results in an 
inability to digest properly all other elements. 
Therefore, it is clear that all of our resources must 
be watched, as probable trouble causers, and their 
proportion particularly regarded in the readjust- 
ment of food to the capabilities of a deranged di- 
gestion. When it is shown that an infant is re- 
ceiving a sufficient supply of food and yet is not . 

74 



DIGESTIVE DISTURBANCES IN ARTlFlCAI,I,Y FED. 75 

gaining, or is becoming atrophic, a careful history 
of the food of such an infant will most likely dis- 
play at some time an overtaxed digestion from an 
excess of one or all food elements and rarely from 
a deficiency of these. Whenever a disproportion 
occurs between the digestive powers and the work 
put upon them, trouble is sure to ensue. This 
trouble may be acute, ending occasionally in death, 
generally in a recovery, but not infrequently de- 
velops gradually into a chronic indigestion. Diges- 
tive disturbances, therefore, may well be divided 
into acute and chronic. 

Acute Indigestion. 

Gastric Indigestion of Nervous Origin. — This 
is a disturbance of the digestive power of the stom- 
ach through nervous influences such as sudden or 
prolonged overheating (heat stroke), fatigue, un- 
due excitement, such as playing with a child too 
much, etc., fright and other emotions (usually in 
older children). This type is characterized by vom- 
iting, usually precipitate and without much nausea, 
vomiting being rarely prolonged. It usually clears 
up after the stomach is entirely emptied; fever is 
either absent or moderate, rarely high, for a few 
hours. 

Indications for Treatment. — If the stomach is 
not completely emptied as indicated by continued 
vomiting, a stomach washing may be necessary, al- 
though cases requiring this are exceedingly rare. 
Give the stomach a rest for a while, usually for 



76 INI^ANT CEDING. 

ten or twelve hours, and administer a suds enema; 
a purgative is sometimes advisable. Calomel is 
best under these circumstances since other purga- 
tives are apt to be promptly vomited; it is best 
to give the calomel in small repeated doses — for 
example, one-tenth of a grain every half hour for 
five or six doses is usually sufficient. The day fol- 
lowing, the food should be cut down to one-half 
the strength and by the second day it is usually 
safe to return to the full diet. 

True Acute Gastric Indigestion. — This is usual- 
ly due to a ''food outrage,'' that is, too much or 
too concentrated food or to a great preponderance 
of one of the food elements. Fat and sugar are 
the elements which most frequently cause trouble. 
This type is characterized by the vomiting of food,, 
frequently clabbered to such an extent that it forms 
a complete cast of the stomach. The vomiting is 
more or less persistent and may continue for sev- 
eral days in an acute form so that everything taken, 
even water, is vomited. If this class of cases is 
not promptly and properly handled, then the 
chances are very great that they will pass into the. 
chronic form. The fever is very slight or sudden- 
ly and briefly high unless true gastritis intervenes 
in which event a continuance of the high fever is 
the rule. 

Indications for Treatment. — The first indication. 
is to empty the stomach. The vomiting usually 
ceases of its own accord just as soon as the stom- 
ach is emptied completely, but if the vomiting is 



dige:stive disturbances in artificai,i,y ^zd. 77 

persistent, stomach washing should be done with- 
out delay ; usually one washing will suffice, but if 
not, it should be repeated. An enema should al- 
ways be given to empty the lower bowel to pre- 
vent a continuance of vomiting from toxic absorp- 
tion. Calomel may be exhibited as in the ner- 
vous type but if this induces vomiting it should be 
stopped at once. The second important indication 
is a complete and continued withdrawal of food 
and a very gradual return to normal diet. The 
stomach should be given a complete rest for at 
least twenty-four hours ; by this I mean that noth- 
ing whatever, not even water should be given by 
mouth; a rigid adherence to this cannot be too 
strongly emphasized. We should then give very 
small quantities of boiled water, gradually increas- 
ing the quantity until we are sure that the stom- 
ach is not going to rebel. When we have reached 
this stage, we may begin to give very small quanti- 
ties of very diluted food. To begin with, the least 
possible percentages should be used. For infants 
under six months old either whey made from skim 
m.ilk, which gives a formula of fat, 4.5 sugar, 
.90 whey proteid ; or even in some instances di- 
luted whey. In cases occurring after six months, 
cereal water may be given instead of whey, al- 
though whey is exceedingly useful at all ages. 
When the infant is taking the whole whey or ce- 
real water with impunity we may begin to add milk 
ingredients. Since the fat is more frequently the 
cause of trouble it is best to start with small 



78 INFANT i^E^DDING. 

amounts of skim milk so as to make the proteid 
as low as .50 per cent, then .75 per cent, then 1 per 
cent. When the skim milk is added to whey, we 
have a split proteid, in this case the per cent of 
proteid referred to being the casein ; the whey pro- 
teid remaining constant. By the time the child has 
gotten up to 1 per cent of proteid we may begin 
to add fat, first, as small an amount as .50 per cent 
or in some instances .25 per cent and gradually in- 
crease. After attacks of this kind the infant may 
take the fat badly for a long time and I have found 
that under these circumstances the fat is better 
borne in the presence of malt sugar than any other 
form. The vomiting in acute gastric indigestion 
must always be distinguished from the nervous 
type, ''recurrent vomiting," commencing infectious 
diseases (rare under one year), toxemia, etc. 

Acute Intestinal Indigestion. 

Nervous. — There is a nervous diarrhea in every 
respect analogous to the nervous vomitmg. It may 
or may not be accompanied by vomiting; the causes 
are the same and need not be repeated. Its char- 
acteristics are a mild diarrhea without straining; as 
a rule stools well digested and devoid of mucus or 
blood; fever is moderate and of short duration if 
present at all; prostration slight. 

Indications for Treatment.-^E^ssQntislly the same 
as in nervous vomiting just described, if vomiting 
accompanies it ; if there is no vomiting, an initial 
dose of castor oil or milk of magnesia, the former 



DIGEJSTIVK DISTURBANCE'S IN ARTlFlCAI,I,Y I^E^D. 79 

preferably, and cutting down the food strength one- 
half or more until acute symptoms have subsided; 
after this, a gradual return to normal food may be 
allowed. 

True Acute Intestinal Indigestion. — This con- 
dition is usually due to a sudden disturbance of 
the proportion between the digestive power and 
the food. Its characteristics are slight fever which 
is not persistent; the stools are loose, lumpy, not 
well digested, rarely green or foul; blood and mu- 
cus invariably absent unless the diarrheal condi- 
tion is prolonged; straining is absent or slight; 
vomiting may occasionally be present. 

Indications for Treatment. — The same as in 
gastric indigestion if accompanied by vomiting, if 
not, an initial dose of castor oil should always be 
given and food should be cut down to one-half or 
less for a day or two or until acute symptoms have 
subsided, then a gradual return to normal, bearing 
in mind as stated above that the fat is less well 
borne than the proteid. In intestinal indigestion 
as in gastric, malt sugar is especially serviceable af- 
ter the diarrheal symptoms have subsided by aid- 
ing in the digestion of fat and also in promoting a 
gain in weight. In all of the cases just mentioned 
an initial loss of weight is the rule and to be ex- 
pected, but the keynote in handling them is that 
the weight is secondary in importance to the re- 
lief of symptoms. After we are quite sure that the 
child is assimilating its food properly, we may then 
begin to look after the weight. An infectious diar- 



80 INF^ANT I^EEDING. 

rhea may be regularly implanted on an acute in- 
testinal indigestion, which, however, will be consid- 
ered in a separate chapter. It is well to bear in 
mind that intussusception is often mistaken for this 
condition when there is vomiting and blood in the 
stools. 

Chronic Gastric Indigestion. 

This condition may immediately supervene on 
an attack of acute gastric indigestion or it may 
develop so gradually that it is hardly noticed by 
the parents, in which event it is due almost always 
to the continued use of the wrong kind of food or 
to bad habits. I find this condition most frequent- 
ly where too strong dilutions of cow's milk have 
been used or the continued use of proprietary 
foods rich in sugar; however, any irregularity in 
feeding may be responsible. This condition is 
usuall}^ present in chronic constitutional diseases. 
It is characterized largely by vomiting of either 
large or small amounts of the stomach contents ac- 
companying or immediately following feeding, or 
very frequently small amounts are vomited at ir- 
regular intervals. One of the most constant man- 
ifestations is the vomiting of ''sour water" as so 
frequently described by the mother. The child's 
appetite may be very meager or it may take with 
avidity any food which is given it only to vomit it 
very promptl3^ This is due to the child's mistak- 
ing the discomfort of the indigestion for hunger, 
there is either stationary weight or loss of weight. 



DIGESTIVE DISTURBANCES IN ARTIFICAI.I,Y I^ED. 81 

The abdomen is almost always hard and distended. 
This condition may be an accompaniment of chronic 
intestinal indigestion or the intestinal symptoms 
may predominate which gives us the true type of 
chronic intestinal indigestion. 

Chronic Intestinal Indigestion. 

The causes of this condition are essentially 
those mentioned in the preceding paragraph. This 
condition is one that is comparatively common in 
breast fed infants though of course more frequent- 
ly seen in those artificially fed. I believe that the 
vast majority of these cases are produced by the 
prolonged use of proprietary foods, particularly 
those which are rich in starches. The character- 
istics are either continuous diarrhea or an obstinate 
constipation or an alternation of these conditions 
usually accompanied by mucus in the stools, some- 
times blood and almost invariably a great deal of 
flatus. Stools are frequently so irritating that they 
cause excoriation of the skin, this is particularly 
true where there is fermentation due to starch and 
sugar ingredients. The stools may or may not 
contain mucus and are seldom exceedingly foul 
though the green color usually predominates. In 
the constipated cases the stools may be hard and 
firm, clay colored, and frequently have scybalous 
masses. It is needless to say that there is almost 
always a steady loss of weight and it is these cases 
which result in the development of the typical ma- 
rasmus infant. 



82 INFANT i^EEDING. 

Indications for Treatment. — These chronic in- 
digestion cases, both gastric and intestinal, are so 
clearly dietary that they will be discussed in the 
chapter on difficult feeding cases. 



CHAPTER X. 

HANDLING OF DIFFICULT FEEDING 
CASES. 

I HAVE stated that the feeding of a healthy baby 
on the bottle was a problem of comparative 
simplicity. The feeding of an infant with a de- 
ranged digestion is the most difficult problem that 
I have ever been called upon to undertake in the 
field of medicine. Nothing taxes the judgment or 
the knowledge of the underlying principles of di- 
gestion so much as this and upon the knowledge 
and judgment born of long experience depends 
whatever success we may attain. 

There are two great classes of infants which 
present difficult problems in feeding — first, those 
who from prematurity or congenital weakness are 
capable of digesting only the weakest dilutions of 
the ingredients of cow's milk; who have to be 
watched constantly and carefully for the slightest 
derangement of digestion; the second, and by 
far the larger group, are those whose digestion has 
become deranged as a result of improper methods 
of feeding. Both of these classes require particu- 
lar attention to be paid to the following points: 
the capacity of the stomach, by a fair estimate of 
which alone are we enabled to determine the 

83 



84 INFANT FEEDING. 

amount to be given at each feeding, and the period 
of time required for the individual stomach to 
empty itself; a frequent estimate of the gain in 
weight and a most careful watching of the stools. 
These cases present problems which are difficult 
for the most astute observer to solve and in many- 
instances it is unfortunately true that the prob- 
lem is never solved. 

The error which I see most frequently made is 
in not giving the digestion a fair trial on any one 
formula, and one constantly sees changes made as 
often as every day; in such rapid succession, in 
fact, that the child is in reality upset because of 
this very rapid change. As a general rule, three 
days is the shortest time in which we may observe 
the effects of a change on the digestion. These 
cases cannot be handled by a rule of thumb, but 
one rule must be observed, namely, such a formula 
must be used as will give us a patient who is prac- 
tically symptom free, who has no vomiting, no colic, 
stools approximately normal. When this degree 
of dilution has been reached, it must be maintained 
until the child is hungry, proving that a truly hun- 
gry child means one whose digestive power has 
reached the stage at which it demands more food. 
After we have secured these two conditions, we 
may then safely endeavor to increase the infant's 
weight. To accomplish this, it has certainly been 
borne out in my personal experience that modi- 
fications of cow's milk are still to be our main re- 
liance, but one important point must be borne in 



HANDIvING 01^ DU^FICUW FEEDING CASES. 85 

mind; the proportions of the three main elements, 
and especially the fat and the proteid, must be re- 
duced to begin with to the smallest possible quan- 
tity at which life can be maintained. I have never 
seen any advantage to be derived from condensed 
milk. If one will only stop and consider carefully 
the formulae of the various condensed milk dilu- 
tions, he will see that the same proportions can be 
obtained from modified cow's milk, and in my ex- 
perience, much more advantageously to the re- 
quirements of the infant digestion. I have found in 
these cases whey to be of inestimable value. This 
may be made, according to indications, from whole 
milk or fat free milk, that is, skim milk. In the 
first instance we have a formula approximating .90 
fat — 4.50 sugar — .90 whey proteid, while whey 
from skim milk contains the same formula with a 
theoretical zero percentage of fat, while, practical- 
ly, I think we still have about .05 per cent. It is 
occasionally necessary to start these cases for 
twenty-four or forty-eight hours on even diluted 
whey mixtures before they can be freed from va- 
rious symptoms, but naturally these preparations 
cannot maintain life very long and it is essential 
to add the other ingredients gradually, commenc- 
ing with the addition of small quantities of skim 
milk always in such proportions as to give us a 
more or less definite idea of the percentage of pro- 
teid given and even to begin on the lower percent- 
ages of fat by the addition of the necessary quan- 
tity of cream. 



86 INFANT FEEDING. 

According to Holt the three main groups of 
these cases are as follows : first, those whose chief 
symptom is habitual vomiting or regurgitation of 
food; second, those with intestinal symptoms, most 
frequently with loose stools; third, those with no 
marked symptoms of indigestion yet whose weight 
is much below the average, who do not gain on 
weak food and yet are upset by stronger food, who 
have feeble digestion rather than indigestion. To 
these cases I would add a fourth group, those who 
take apparently normal preparations of food and 
who are habitually constipated and do not gain. 

The cases in which vomiting is the main symp- 
tom are, as a rule, the easiest to handle. If we bear 
in mind what has already been said about the causes 
of vomiting we will find that these cases are just 
as abundant in the class of cases under observation 
as they are in the acute forms and the too frequent 
feeding of too large amounts at each feeding or too 
much handling play important parts, but from the 
standpoint of the food element, fat again comes to 
the front as a trouble maker. However, sugars may 
also cause this, particularly the malt sugars, and 
this is perhaps the reason why we see so many of 
these cases following the use of many of the pro- 
prietary preparations. These cases for a while re- 
gurgitate, as a rule, only small quantities of undi- 
gested food or sour milk, sometimes merely a wa- 
tery fluid which is the second step in the process 
of indigestion, finally, mucus forms a large part of 
the vomited matter. 



HANDI.ING OF DIFFICUI.T FEEDING CASES. 87 

In the intestinal group we may have diarrhea 
in which there is either a large number of partially 
digested stools or a typical fluid stool in which mu- 
cus sooner or later appears in large quantities. 
Colic is not the rule, but it may occasionally occur 
as may also constipation. As in the former class 
of cases, the fat is most to be blamed, but frequent- 
ly we find again the combination of fat and sugar 
intolerance. In the third named group above it is 
exceedingly difficult to determine what is the cause. 
As a rule, we will find some constitutional disturb- 
ance in Which general measures such as fresh air, 
change of climate, etc., play the most important 
part in the treatment. In the fourth group which 
has been added by the author, the cause is also dif- 
' ficult to determine. In this group, I think it is wise 
in addition to the general measures such as have 
just been mentioned, to begin all over again, as it 
were, on diluted preparations of all ingredients and 
work up de novo as if we were dealing with a fresh- 
ly weaned child. The only drug in any of these 
cases which I think does any particular amount of 
good is nux vomica in small doses, which seems 
to have a stimulating influence on all the digestive 
functions. The management of all these cases re- 
quires the most careful watchfulness. As a rule 
we can succeed only after a careful examination of 
the stools both macroscopically and microscopical- 
ly to determine what food element is passing 
through the digestive tract without having been 
acted upon. When we can discover this, we have 



88 INI^ANT FEEDING. 

usually accomplished a great deal in the treat- 
ment, while a computation of the balance between 
the caloric needs of the child and the amount be- 
ing taken is indispensable. I 'have repeatedly stated 
that fat, at least in my experience, is best handled 
in the presence of malt sugar but right here lies a 
danger point. It is comparatively easy to correct 
the trouble if we discover that there is an intol- 
erance for one food element, but where fat and 
sugar have both been given in excessive quantities 
and fat and sugar intolerance have both been es- 
tablished, we have one of the most difficult prob- 
lems to handle of which I know. In these cases, 
I think the Eiweiss-Milch of Finkelstein is a great 
help, but it is undoubtedly of more benefit in diffi- 
cult cases of the second year than of those of the 
first year. As a rule, in all these cases a formula 
which is exceedingly low in fat, a sugar content 
of from 3 to 4 per cent and proteid not exceeding 
1.5 per cent helps us a great deal and here again 
I find the whey mixtures of great value. Occa- 
sionally we find buttermilk to be of advantage and 
not infrequently the stopping of all milk products 
for a limited period of time, not exceeding five to 
seven days, is absolutely necessary. In these cases, 
a wet nurse is only too frequently more harmful 
than she is beneficial. Our old rule will help us 
here as well as in the acute cases, that is, starting 
with a formula which is exceedingly low in all 
food elements and keeping on this formula until 
the infant is symptom-free and then gradually in- 



HANDI.ING OF DIFFICUI.T FEEDING CASEvS. 89 

creasing during tlie period in which we endeavor 
to stimulate the appetite, we can then safely go to 
the development of flesh. Long intervals of nurs- 
ing with small quantities are invaluable in these 
cases. In this way better than any other we can 
induce the feeble digestion to care for the food ad- 
ministered and at the same time produce a desire 
for an increase. Many of these children may run 
low temperatures, but only too frequently the tem- 
perature may be sub-normal showing a very poor 
recuperative power. 

In all these discussions, I have dwelt on general 
principles leaving to the study and ingenuity of 
the physician the actual formulae which should be 
used, for I do not believe any rules can be laid 
down by which a child may be fed, or stated for- 
mulae given for different children and conditions. 
A suggestive outline may be helpful, however. If 
we have started with whey we have a formula 
which is either — 

F S WP 

.90 4.50 .90 

if whole milk has been used, or — 

F S WP 

.0 4.50 .90 

if skim milk has been used. The latter is prefer- 
able when we have a fat intolerance. Then the in- 
crease may be made as follows — 

.0 4.50 90/10 (split proteid) 

.0 4.50 75/25 



90 INFANT I^E^DING. 

and if by this time we think fat can be well borne 
we may make the whey formula partially skim milk, 
giving approximately — 

.50 4.50 75/25 ' 

.90 4.50 75/25 

then from whole milk. When this has been borne 
for a day or two we may be able to discard the 
whey and give such a formula as — 

.75 4.50 1.00 

If the case has been one of fat intolerance it is best 

to increase the proteid first and then the fat. 

Thus — 

.75 4.50 1.25 

1.00 5.00 1.25 

1.25 5.00 1.25 

1.25 5.50 1.50 

1.50 5.50 1.50 

2.00 6.00 1.50 

— and so on. 



CHAPTER XL 

INFANT FEEDING DURING THE SECOND 

YEAR. 

IN my experience, the feeding of healthy infants 
during the second year is a more difficult prob- 
lem than during the first year and difficult cases 
occurring during this period present the hardest 
problem of all feeding. Authorities differ widely 
as to the proper time at which a baby should be 
weaned from the bottle. I think a safe average is 
at the twelfth month; lusty babies may be given 
small articles such as dry bread to chew before 
this period; the physical condition of others may 
demand that the bottle be kept up for some time 
longer. Certainly by the fifteenth month all milk 
which a baby consumes should be taken from a 
cup rather than a bottle. It is seldom that infants, 
for the first few months after the bottle stage is 
ended, can take whole cow's milk. It is, therefore, 
advisable to dilute the milk with some cereal gruel. 

Below will be given a suggestive schedule for 
feeding at the various months during the second 
year. 

Second Year. — Regularity of feeding is as es- 
sential as during the first year. The child should 
not be allowed to eat anything between the regu- 

91 



92 INFAXT ]?EEDING. 

lar hours, nor should it be tempted with this or 
that thereby becoming a ''taster/' As soon as pos- 
sible the cup should be substituted for the bottle. 
If this is not done, the child is apt to cling to the 
bottle as late as four or five years of age. Small 
amounts of cereals, toast, dry bread and zweibach 
should be tried at first and then we may branch 
off to other things. An artificial food which is 
common in the South and not elsewhere is batter- 
bread or ''spoon-bread'' which consists mainly of 
corn meal and eggs and is very wholesome. I find 
this as good as cereal and at the same time gives 
the eggs in a very digestible form. A general sug- 
gestive schedule follows : 

For the first few^ months after weaning from 
the bottle we may use one of the two following 
schedules according to how the child has been fed 
during the previous months. 

I. 

6 to 6:30 a. m. Milk diluted ^ with cereal gruel. 
8:30 to 9 a. m. Orange juice. 

10 a. m. Milk and gruel. 

12 a. m. Bread (dr}^, toast and broth. 

6 and 10 p. m. Diluted milk. 

If a child is further advanced in feeding than usual we 
may use the following: 

II. 

7 a. m. Cereal, oatmeal, barley, wheat or hominy grits 
and diluted milk from cup. All cereals cooked for at 
least three hours in double boiler. 

9 a. m. Orange juice. 

11 a. m. Dry bread, broth, soft boiled tgg (at first 



INI^ANT FEEDING DURING THE SECOND YEAR. 93 

the egg should be given every third day, then oftener), 
milk (use less and less dilution until by the fifteenth or 
■sixteenth month we are using whole milk). 

2 p. m. Baked potato, mashed with butter or drip- 
pings from steak or roast. (Must be kept fat free.) Beef 
juice is preferable. 
5 and 9 p. m. Milk. 

III. 
(15th to 20th month) 

7 to 8 a. m. Breakfast: Cereal, bread and milk, or 
batter-bread. 

12 a. m. to 1 p. m. Dinner: Egg, potato, green vege- 
tables, such as spinach and carrots (these may color the 
stools and pass through apparently undigested at first but 
this, as a rule, does not matter), beef juice, broth, rice 
and a dessert of rice or tapioca pudding, with little or no 
sugar. 

5 to 6 p. m. Supper: Bread (toasted bread, or dry 
bread), cup of milk. 

10 p. m. Milk (undiluted). 

IV. 

By the 20th month we may safely give the following, 
three meals a day usually being sufficient: 

7 to 8 a. m. Breakfast: Cereal, batter-bread, toast or 
dry bread, egg, soft boiled or coddled, a little stewed fruit 
or scraped apple. Where fruit is not used at this time, 
orange juice may be given as above. 

11 a. m. to 1 p. m. Dinner: Scraped beef, minced 
chicken, oysters (hearts cut out), finely cut up lamb, 
broths, potatoes (postpone the sweet potatoes until later 
as they cause fermentation), spinach, asparagus tips, car- 
rots, rice; desserts of blanc mange, custards, rice and 
tapioca puddings, etc. 

5 to 6 p. m. Supper: Bread, toasted hard or dry bread, 
cup of milk, stewed and sometimes raw fruits. 

Use very little sugar in cooking fruits or puddings; 
never use as a simple sweetening. Candy should never 
be given until five or six years of age. 



94 INFANT FEE^DING. 

Difficult Cases During the Second Year. — A 

number of children pass through the first year in 
a state of unstable equilibrium from slig'ht errors 
causing derangements of digestion. It is needless 
to say that these children enter the second year 
handicapped and form the first group of difficult 
feeding cases during the second year. In this group 
of cases it may be necessary to prolong the bottle 
feedings and even when solid food becomes a set 
portion of their diet, a modification of cow's milk 
may have to be carried on with the same care as 
during the first year. However, the danger must 
always be borne in mind of keeping the child on 
liquid diet too long because the digestion in this 
way is not stimulated to the activity which is nec- 
essary to the early years of childhood. 

There is another class of cases which will go 
along on rational food for the second year for 
longer or shorter periods and suddenly have a com- 
plete breakdown, especially from the intestines. 
These are cases which are poorly understood. 
Where they are watched carefully, of course, the 
majority of them display an indiscretion on the 
part of the parent or physician in attempting to 
push the solid ingredients of food too rapidly. As 
a rule, this class of children take care of beef juice 
and broths better than the dilute vegetable prod- 
ucts and yet the vegetable juices are so essential 
to child growth that they must be used if possible. 

In deranged digestion during the second year, 
fruits are rarely well borne while sugars are posi- 



INFANT I^EEDING DURING THE) SECOND YEAR. 95 

tively contraindicated. In many instances I find 
that where sweetening is necessary in order to 
make the child take the food it should, a solution 
of saccharine is preferable to the standard sugars. 
In this class of cases more than any other is a care- 
ful examination of the stools necessary and, as a 
rule, it is wise to allow the child to have a more or 
less liberal diet during which time a careful study 
of the stools is made, both macroscopically and 
microscopically, to indicate all foods which show 
a passage through the digestive tract undigested. 
They can then be eliminated and a return to them 
should be exceedingly gradual in order to develop 
a tolerance. This class of cases requires infinite 
patience and perseverance on the part of the phy- 
sician and absolute acquiescence on the part of the 
parent. 

Most frequently fats are at fault, but by no 
means infrequently the sugars. In these the Ei- 
weiss-Milch of Finkelstein is exceedingly valuable. 
When the fat is at fault children become and re- 
main symptom-free more readily on this mixture 
than any other of which I know, but the weight 
is inclined to remain stationary. When they have 
reached a point, after weeks or months of this diet, 
when it appears safe, we may add an increasing 
percentage of malt sugar, which usually starts the 
weig'ht upward very rapidly. If we are sure that 
there is no sugar intolerance we may begin with 
a liberal percentage of malt sugar in the Eiweiss- 
Milch. 



96 INFANT FEEDING. 

These cases require months of most careful 
watching and the physician should impress this fact 
upon the parent very early. In many instances we 
are compelled to return to first year modifications 
of milk for sick infants for a while, in which case, 
the principle should be low fat, high proteid, mod- 
erate carbohydrate at first, but as soon as appears 
safe the carbohydrate may be increased gradually 
to reach a high proportion. Care must be taken, 
however, not to push this to the point of intoler- 
ance. 



CHAPTER XII. 

MARASMUS. 

THIS condition is one that has been variously 
known as marasmus, arthrepsia and simple 
atrophy. Clinically it represents an extreme state 
of malnutrition following prolonged digestive dis- 
turbances, or the child may have ceased to gain in 
weight upon weaning and have no marked diges- 
tive disturbances other than the failure to gain in 
weight. The usual history of these cases is ''since 
weaning, everything has been tried, including milk 
modifications, proprietary foods and condensed 
milk and nothing has seemed to agree with the in- 
fant.'' As a matter of fact the first inception of 
marasmus is due, in the large majority of cases, 
to ignorance in handling after the necessary or un- 
necessary weaning. The most frequent error which 
I observe in histories is in giving too strong di- 
lutions of cow's milk or too large feedings. It is 
most frequently seen before the ninth month al- 
though a not inconsiderable number of cases oc- 
cur during the last of the first year and even the 
first half of the second year. 

Marasmus is characterized primarily by wast- 
ing to such an extent that a child of nine months 
may weigh little more, if any, than it did at birth. 

97 



98 INSTANT I^E:KDING. 

The infant gives one the impression that the skin 
is hanging in folds on a skeleton, the fontanel is 
sunken, abdomen abnormally distended showing 
thin walls with the veins prominently outlined, the 
cry is more like a feeble whine. All of these condi- 
tions, as intimated above, may develop without any 
apparent digestive disturbances such as diarrhea 
or vomiting although constipation is quite com- 
mon. On the other hand there may be occasional 
outbreaks of both vomiting and diarAea. It is es- 
sentially a condition of the poorer classes in crowd- 
ed tenements and institutions which are over- 
crowded and do not furnish a sufficient amount of 
fresh air for infants or a sufficient number of nurses 
to care for them. It is occasionally, however, seen 
among the well-to-do. It furnishes us with a ser- 
ious problem both from the standpoint of preven- 
tion and of cure and yet, if properly handled, there 
are few conditions of child life which furnish a 
better opportunity for more brilliant results. 

Treatment. — The most essential factor in the 
treatment of marasmus is prophylaxis. Maternal 
feeding is an essential in its prevention. To this 
end mothers in the poor sections especially should 
be educated to nurse their infants, not only from 
the importance to the infant itself, but from the 
standpoint of economy. If they can once be shown 
that breast milk is far cheaper than even the cheap- 
est of cow's milk, we can impress the importance 
of this matter upon them. Next to this in impor- 
tance is the proper use of pure milk. 



MARASMUS. 99 

In institutions where marasmus is exceedingly 
common, a sufficient amount of fresh air, out-door 
air where possible, proper ventilation when the in- 
fant cannot be out-doors, and a wet nurse will do 
much toward the prevention of the development 
of marasmus. As is well known, it is of common 
occurrence in institutions, but above all, sufficient 
individual care of the infant is important. In the 
average institution there is one nurse to about ten 
infants. It is impossible for these infants to be 
cared for properly under such circumstances. 

In handling the marasmus infant from a correc- 
tive standpoint it is frequently necessary to deal 
with them as if they were premature. The tem- 
perature being often subnormal we place them in 
the basket or bassinet as described in the chapter 
on premature infants with artificial foeat and pre- 
mature garment as also described. Where the wet 
nurse is available, it is pre-eminently proper to se- 
cure her services ; where she is not available, we 
handle this infant as described under difficult feed- 
ing cases, that is, commencing with a food low in 
proteid and fat, but rather high in carbohydrate 
since these cases not only need the heat producing 
material but take carbohydrate unusually well and 
assimilate it quite promptly. After being sure that 
a tolerance for fat and proteid has been established 
we gradually increase these two until a reasonable 
formula for a child of their age is being taken. I 
believe that far more is accomplished through this 
means than any other. However, the followers of 



100 INFANT FEEDING. 

Finkelstein claim brilliant results from the use of 
Eiweiss-Milch and I have seen occasional cases 
where good results were obtained, but find better 
results in the digestive disturbances during the sec- 
ond year than the marasmus of the first year. The 
mistake 'has been made in not giving carbohydrate 
while Eiweiss-Milch is being administered until the 
stools have become pasty. Three per cent of malt 
sugar should be administered from the first, after- 
wards running up to as high a per cent as the child 
will take. The method of preparation of Eiweiss- 
Milch will be found in the appendix. 



CHAPTER XIII. 
INFECTIOUS DIARRHEA. 

BY the term ''infectious diarrhea" is meant that 
group of diarrheas which is caused by infec- 
tious organisms. This has been proven in certain 
instances by laboratory experiments, w^hile in other 
cases it is assumed from the clinical manifestations. 
These diarrheas are not essentially food outrages 
though, of course, food outrages may precipitate 
the disturbance by lowering the digestive power of 
the intestines thus affording infectious organisms 
a suitable culture medium. 

This form of diarrhea may occur at any time of 
the year and among any class of people, though it 
is far more common among the poor than among 
the well-to-do and its greater frequency during the 
hot months has led to the term ''summer diarrhea." 
This type of diarrhea is familiar to all who deal 
with children hence various manifestations and 
variations of type will be only briefly outlined. The 
onset is usually sudden though it may be gradual; 
the intestinal symptoms predominate if sudden; 
gastric symptoms are frequently present and oc- 
casionally predominate. There may be colicky 
pains in the abdomen, or aching limbs or a feeling 
of malaise before the appearance of the diarrhea 

101 



102 INFANT I^EEDING. 

though in the majority of instances these symp- 
toms are absent. The average case commences 
with loose bowels which are at first fecal and may 
or may not contain blood or undigested food. On 
the second day the stools are very foul and green; 
streaks of blood may appear at this time, but more 
frequently the blood and mucus appear the third 
day. From this time on, the blood and mucus pre- 
dominate interspersed with occasional greenish 
fecal passages. Macroscopic pus is usually pres- 
ent after four or five days but it can almost always 
be demonstrated under the microscope earlier. 
There are also cases in which membrane is pres- 
ent and occasionally to such an extent as to be 
gangrenous in which event there is an exceedingly 
foul odor ; under these circumstances, the odor may 
be little worse than disagreeable. The number of 
stools varies from five or six in twenty-four hours 
to twenty-five or thirty in severe cases. Tenesmus 
is frequently a distressing symptom. The temper- 
ature is rarely high in typical cases ranging from 
100 to 102 at first and falling rapidly with the ap- 
pearance of blood and mucus. Mild cases may be 
reasonably near recovery by the end of one week 
while the average case lasts from two to three 
weeks. A case of even moderate severity may last, 
with remissions, from two to three months being 
relieved finally only on the advent of cool weather. 
Of course death may occur in prolonged cases of 
moderate severity from exhaustion, the child laps- 
ing into a stuperous condition with marked asthenia 



INFECTIOUS DIARRHEA. 103 

closely resembling what is known as the ^^typhoid 
state." The prostration is usually pronounced and 
loss of weight is rapid, both of these depending in 
large measure on the severity of the attack. Vari- 
ations from typical cases are numerous and a few 
will be cited. 

The onset may be so violent as to be best de- 
scribed as explosive. In such cases the temperature 
is apt to be higher than the average case, reaching 
as high as 105 or 106, the stools being bloody almost 
from the first and exceedingly frequent. In in- 
stances of this sudden onset vomiting is not un- 
usual and in such cases the prostration is profound 
and appears early, loss of weight is so rapid as to 
be apparent in a few hours, the eyes and abdomen 
are sunken, though rarely the latter may be dis- 
tended. The suddenness and violence of these 
cases suggests the theory of heat stroke very 
strongly. As a rule diarrhea is so pronounced and 
prostration so rapid in its increase that death may 
take place before the appearance of blood in the 
stools. 

A number of these cases start with constipa- 
tion which is so persistent that it is with great dif- 
ficulty that we secure a movement at all. There is 
apparently toxic paralysis of the bowels and when 
they are finally evacuated the stools are exceeding- 
ly foul, blood and mucus being present from the 
first. The temperature in such cases is uniformly 
high until full evacuation of the intestines is se- 



104 INFANT FEe:dING. 

cured. In this type an onset with convulsions is 
occasionally met with. 

Some cases of infectious diarrhea respond quick- 
ly to treatment while others in spite of proper 
treatment die early. If the onset is violent emacia- 
tion is apt to be pronounced at once, if, on the 
other hand, the onset is gradual, emaciation may 
be slight, some children passing through the whole 
summer with surprisingly slight loss of flesh. The 
type varies with different years, during some years 
there is marked tendency to enlargement of the 
liver, which is, however, by no means constant. 
These diarrheal conditions are responsible for a 
very large per cent of infant mortality and a satis- 
fa^ctory etiology has not as yet been worked out, 
although certain factors are well recognized as play- 
ing important parts. 

Infectious diarrhea is exceedingly rare among 
breast fed babies being most commonly observed 
among bottle fed babies during the first year. 
There is a marked diminution among the number 
of cases after the eighteenth month. A few cases 
occur among the well-to-do but by far the greater 
number are found among the poor. It is essen- 
tially a disease of the summer months though it is 
occasionally met with during other seasons of the 
year. Certainly along the Atlantic seaboard heat 
plays a very important part in the etiology. I des- 
ignate Atlantic seaboard specifically because the hot 
weather incidence is not so marked on the west 
coast, while the intense heat of the prairie region 



INI^]eCTlOUS DIARRHEA. 105 

west of the Mississippi has apparently little effect. 
This brings, however, forcibly to our attention the 
question of ^'relative humidity,'' the east coast hav- 
ing a high relative humidity while west of the Mis- 
sissippi, generally, the 'humidity is quite low. A 
temperature of 90 degrees with relative humidity 
of 80 degrees is almost unbearable in the east, while 
in the west a temperature of 110 or 115 will not be 
uncomfortable; it will be found, however, that in 
regions of the west where this intense heat pre- 
vails the relative humidity is frequently as low as 
8. This suggests strongly that radiation, or, rather, 
lack of radiation, has much to do with the incidence 
of these bowel disturbances. 

I have studied this question closely for a num- 
ber of years and am firmly convinced that the sub- 
ject of radiation furnishes us, a fertile field of in- 
vestigation. 

Overcrowding in the badly ventilated houses of 
the poor where the temperature is often from 5 to 
10 degrees 'higher than out of doors together with 
too heavy clothing are important causative factors. 

The question of milk supplies has received much 
investigation and while unclean milk undoubtedly 
causes many cases of diarrhea. Park and Holt have 
shown very clearly that this source of infection has 
been greatly overestimated. Until quite recently no 
very satisfactory conclusion has been reached from 
the study of the bacteriology of this disease. Dur- 
ing the past three years, however, important ad- 
vances have apparently been made in the study of 



106 INFANT I^e:EDING. 

intestinal bacteriology. Excellent work has been 
done by Kendall and Smith on the Boston Float- 
ing Hospital. They found that, etiologically, there 
are three groups — those caused by the dysentery 
bacillus, those caused by the gas bacillus, and those 
caused by other organisms of which the most im- 
portant are the streptococci, the colon bacillus and 
the bacillus pyocyaneus. Clinically, the disease 
caused by any of these groups is indistinguishable 
but, from a therapeutic standpoint, it is exceeding- 
ly important that they be distinguished. For prac- 
tical and therapeutical purposes we may consider 
the gas bacillus in a class by itself while the dysen- 
tery bacillus group may include also all the other 
organisms mentioned above. ''The dysentery bacil- 
lus, the colon and streptococci are facultative and 
thrive on either carbohydrate or protein." They 
produce harmless products from carbohydrate and 
toxic from protein. However, they act upon and 
use up the carbohydrate material before they at- 
tack the protein when both are present in the me- 
dium in which they are growing (intestines) and the 
products resulting from the breaking down of the 
carbohydrate material, when produced in sufficient 
quantities have an inhibitory action upon the dys- 
entery bacillus. On the other hand, the gas bacil- 
lus grows luxuriantly in the presence of utilizable 
carbohydrate while lactic acid inhibits its growth. 
An accurate determination of the type of organism 
which is responsible for the particular case of diar- 
rhea requires elaborate laboratory methods. A 



INFECTIOUS DIARRHEA. 107 

simple means, however, is as follows : ''A small por- 
tion of the stool is added to a test tube of milk, the 
infected tube is then gradually brought to the boil- 
ing point of water in a water bath and kept there 
for three minutes. In this way all bacteria not in 
the spore state are killed and the development of 
whatever spores may be present into vegetative 
cells is unrestrained by the presence of non-spore- 
forming organisms. The tube is then incubated at 
body temperature for from eighteen to twenty-four 
hours. When the gas bacillus is present the casein 
is largely dissolved; the residual casein is some- 
what pinkish in color and filled with holes ; the 
odor of the culture is like that of rancid butter. 
Gram-stained preparations made from milk show 
rather thick, short Gram-positive bacilli with 
slightly rounded ends.'' The therapeutic test may 
be made by selecting either a carbohydrate or a 
protein food and watching the results. If the symp- 
toms become worse, we are dealing with the op- 
posite microorganism and the food must be im- 
mediately changed. If the symptoms become bet- 
ter, we are presumably on the right track. 

Treatment. — The treatment of this disease is 
both prophylactic and curative. The prophylaxis 
consists first of all in educating people in the care 
of infants. This can be best done in crowded cen- 
ters through visiting nurses who can go into the 
home and teach. 

With the first warm days of summer the cloth- 
ing should be lightened especially during the in- 



108 INI^ANT i^EEjDING. 

tense heat of the middle of the day and the child 
should be allowed to go with nothing except the 
diaper and frequently it is wise to remove this also. 
Infants should be kept out-of-doors in hot weather; 
frequent bathing during the day and where practic- 
able trips to the seashore or on a steamer all day 
where there is a good breeze (in sections where 
this cannot be done a visit to a higher altitude may 
be substituted), go far towards preventing trouble. 
When the milk supply is uncertain, boiling is a 
good precautionary measure. 

I know nothing that can be depended on to 
spread the disease better than a lack of care of the 
soiled diapers. These should be kept covered at 
all times and particularly during the summer they 
should be placed in a solution of bichloride of mer- 
cury and kept there until they can be washed. They 
should never be allowed to stand uncovered and 
exposed to flies, which spread the disease rapidly. 

The medical treatment consists primarily in 
clearing the intestines of all food refuse by means 
of a dose of castor oil. This is decidedly more ef- 
ficient and less drastic than any other purgative. 
A prompt withdrawal of all food, especially milk, 
until the intestines are thoroughly freed from the 
products of indigestion is necessary. The lower 
bowel should be irrigated once with a simple saline 
solution. Boiled water alone should be given for 
the first twenty-four or forty-eight hours and should 
be given in abundance. This is exceedingly im- 
portant since a supply of fluid to the patient is a 



INFECTIOUS DIARRHEA. 109 

positive necessity. As much water must be ad- 
ministered as would be taken in the form of nour- 
ishment. After this is done, a cereal water such as 
barley, given alone at first and then with about 
five per cent of milk or malt sugar, the sugar sup- 
plying some of the needed nourishment. In older 
children we may then begin to give zweibach or 
toast. If the disease is of the violent type we may 
begin with barley water which may be sweetened 
with milk or malt sugar, or, if this is inadvisable, 
with saccharine. Weak chicken broth may be given 
(this contains little or no nourishment but induces 
the patient to take water) ; no beef juice, beef ex- 
tracts or albumen water should ever be given in 
these cases. If the patient does not take enough 
liquid, especially in severe cases, it may be nec- 
essary to administer salt solution subcutaneously. 
Bowel irrigations are advocated by some using salt 
solution or boric acid with a fountain syringe hung 
not more than two feet above the child's hips and 
with a soft rubber catheter. One irrigation a day 
is usually sufficient, certainly not more than two a 
day should be given nor should this be kept up 
too long as they may perpetuate a catarrhal proc- 
titis. 

My own treatment differs somewhat from this 
procedure. I usually give one good flushing and then 
administer small doses of magnesium and sodium 
sulphate by mouth — dose, from 1 to 5 grains each, 
every two or three hours according to the age of 
the patient, to be kept up for about a week. My 



110 INFANT I^E:EDING. 

reason for managing these cases thus is because it 
keeps up a mild irrigation, so to speak, over the 
whole length of the large intestine, while at best, 
an irrigation merely cleanses out the lower part of 
the descending colon. Of course, it is supposed 
that this treatment tends to abstract more fluids 
from the patient and consequently we may have 
difficulty in supplying enough fluids. In my ex- 
perience this has not been the case and I have 
found this procedure exceedingly satisfactory for 
several years. I never use bismuth or salol or 
any other supposed intestinal antiseptic. I have 
found all of them absolutely useless and I 
rarely administer opium. If tenesmus is se- 
vere and a few irrigations fail to relieve it, par- 
egoric may be administered in a small dose only 
until the tenesmus is relieved, hut not enough to 
stupefy the patient. This should never be given 
when the temperature is high or when the stools 
are still fecal or foul, but only when they become 
bloody and with mucus and, generally speaking, it 
is quite safe to wait at least five days, always re- 
membering that the administering of any opiate 
should be discontinued as soon as possible. 

In accordance with the bacteriological findings 
of Kendall and Smith as outlined above, the diet is 
very essential and, incidentally, we must return to 
some definite form of food as early as possible in 
these cases since the mistake was made for many 
years of starving the patient for entirely too long 
a time. As stated above, the bacteriology of this 



INFECTIOUS DIARRHEA. Ill 

condition is dependent on two types — that caused 
by the dysentery bacillus and such organisms as 
the streptococcus and colon bacillus all of which 
require a solution of milk sugar which must be 
given alone until the active symptoms are passed 
and temperature remains normal. The milk sugar 
should be given in a solution ranging from five to 
seven per cent in water and it is better to give fre- 
quent small amounts rather than infrequent large 
quantities. As a rule half as much again of the sugar 
solution should be given as the child normally re- 
quires fluid. We may then add a cereal such as 
barley water containing, as a rule, one per cent of 
starch. When we feel reasonably safe about the 
acute symptoms, we begin to add casein to the ex- 
tent of .50 per cent; then .75 per cent; then 1.50 
per cent — all in the form of skim milk. By this time 
it is probably safe to add .50 per cent of fat. If 
this is well borne, we gradually run up to .75 per 
cent, then 1 per cent, etc. After we have passed 
the period of usefulness of the milk sugar as a di- 
rect therapeutic agent according to the dysentery 
bacillus I think it much wiser to change over to 
malt sugar since in this class of cases malt sugar 
has proven eminently satisfactory in my hands in 
promoting a gain in weight. 

Where the gas bacillus is the causative agent 
as already indicated we use lactic acid. This is 
used in the form of milk ripened with bacillus Bul- 
garicus and not heated. Usually "^ve should make 
up a formula in these cases of fat, 4 per cent milk 



112 INFANT F^EEDING. 

sugar and from 1 per cent to 2^ per cent proteid, 
the whole mixture to be ripened with lactic acid 
bacilli. Since we are using this buttermilk as a ve- 
hicle for the lactic acid bacillus it is evident that 
it is more valuable raw than 'heated. This should 
be kept up until active manifestations have passed, 
it being exactly analogous to the treatment of the 
dysentery type with lactose solution. When we 
feel that the buttermilk has served its purpose, I 
think it best to change rapidly from its use to a 
formula such as fat — 4 sugar — .50 proteid and 
then increase gradually along the lines suggested 
in other cases, always increasing the proteid first. 
In subacute cases where blood and pus persist, 
injections of nitrate of silver are said to be useful 
but I very rarely use them. It has been my ex- 
perience in this type of cases that the best we can 
do is to sustain the patient until the onset of cool 
weather. Stimulants are frequently necessary. I 
believe that alcohol is valueless if not positively 
harmful. Strychnine I use most frequently in doses 
of from 1/1000 to 1/100 of a grain. Caffein and 
camphor are the quickest and are said to act well. 
Cafifein may be used by mouth from % to y^ grain 
while camphor in oil may be given in doses from 
1 to 2 grains. Cool baths as well as cool fresh air 
are very valuable in the treatment but in instances 
of severe shock during a sudden onset it may be 
necessary to use heat. In the subacute or chronic 
cases, change of climate especially to a higher, 
dryer and cooler atmosphere is of undoubted value. 



INFECTIOUS diarrhe:a. 113 

The seashore is also valuable not because it is cooler 
nor because there is less humidity, but because 
there is always a refreshing breeze which promotes 
radiation. 



114 



INFANT FEEDING. 





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CHAPTER XIV. 
PREPARATION OF FORMULA. 

THE preparation of modified milk on a basis of 
approximate percentages has not gained the 
popularity which it merits because of the mistaken 
idea that it is difficult for the physician and im- 
practical for the mother. The statement is often 
made that where a laboratory is convenient it is 
all very well to talk about percentages, but where 
the food must be prepared in the home, it is a dif- 
ficult question. In the vast majority of my feed- 
ing cases the formula is prepared by the mother in 
the home and not in a single instance do I find 
any difficulty in having them prepared quite well. 

The necessary equipment consists of a glass 
graduate measuring 16 oz. in one-half ounces; a 
Chapin cream dipper; round, small-neck bottles 
(Freeman) [the graduation on the sides of these 
bottles should be ignored as they are almost in- 
variably inaccurate] ; a wide-mouth pitcher; a fun- 
nel, preferably glass or white enamel ; a double 
boiler (to be used where the milk is to be heated) ; 
milk sugar ; a tablespoon ; absorbent cotton ; a quart 
bottle of milk. 

In speaking of percentages, the cream referred 
to is 16 per cent cream, which is the gravity cream 

115 



116 INI^ANT i^EjEjDING. 

from a quart bottle of milk. When the milk has 
been allowed to stand until the cream has risen, 
usually four hours, we can take off the upper six 
ounces by means of a Chapin dipper. This gives 
us from an average herd, 16 per cent gravity cream, 
i. e., cream containing 16 per cent of fat; what re- 
mains in the bottle, for all practical purposes, may 
be considered skim milk. The 16 per cent cream, 
the skim milk, the milk sugar, an abundance of 
boiled water, are all that are necessary to make 
the usual modifications of milk. The formula for 
average herd milk as has been given above is 4. 
fat; 4.5 sugar; 3.2 proteid; this latter is variously 
estimated at 3.2 to 3.5. Percentages worked out 
with these ingredients and on the basis of this 
formula for cow's milk, are accurate enough for all 
practical purposes and enable us to modify the milk 
from time to time so as to meet the requirements 
of the infant. 

Average milk contains 4 per cent of fat. The 
visible amount of cream after standing four hours 
is six ounces and contains 16 per cent fat. 

The various formulae are as follows: 

F. 

Milk 4. 

Cream 16. 

Skim milk 0. 

Whey 0. 

Sugar 0. 

Barley water 0. 

(^ oz. to 1 qt.) 

(4 level tablespoonfuls=l oz.) 



s. 


P. 


4.50 


3.20 


4.50 


3.20 


4.50 


3.20 


4.50 


.90 


100. 


0. 


1.50 (carbhy.) 


0. 



PREPARATION 01^ FORMULA. 117 

This equation is all that is necessary to mem- 
orize : 

Let: 

x=no. oz. of ingredient needed (or used). 

a=i:no. oz. ** total mixture. 
y=% " element desired (or unknown). 

h=% " " in ingredient used. 

Therefore all that is necessary is to have an equa- 
tion which is — 

u av ) ., , bx 

X :a :;y :b or x=^ | y will be — 



Example 1. — 

It is desired to give an infant 40 oz. of modi- 
fied milk in twenty-four hours (five feedings of 
eight ounces each) to contain — 

F. S. P. 

4. 7. 2. 

We first determine the number of ounces of cream 
(16%) required to give us the 4 per cent of fat 
desired. The formula will then be — 

X : 40 :: 4 : 16 or x=: 15^=10 oz. of gravity cream (16%). 
16 

That is, X stands for the number of ounces of cream 
needed; a=number of ounces of total mixture (40) ; 
y=% of element desired (4) ; b=% of element in 
ingredient used (16%). 

The next step is to ascertain how many ounces 
of skim milk and cream are needed to give us the 



118 INI^ANT FEEDING. 

2 per cent of proteid. The proteid is contained in 
both the milk and the cream; the formula, there- 
fore, will be — 

u 40X2 

X : a : : y : b or x=- ^\ 
3.2 

X : 40 :: 2 : 3.2=25 oz. skim milk and cream. Since we 
already have ten oz. of cream only 
fifteen oz. of skim milk are needed. 

The next step will be to determine the per cent 
of sugar furnished by the milk and cream. In this 
step y is the unknown quantity (y=% of element 
desired). Therefore the equation will be — 

1 xb 

X : a=y : b or y= — 
a 

25 : 40=y : 4.5 or y=?^><i^=2.8% 
40 

This gives us the per cent of sugar contained in 
25 oz. of skim milk and cream in a 40 oz. mixture. 
Since 7 per cent of sugar is required we need 7. 
minus 2.8 or 4.2 per cent additional. To secure this 
the equation will be — 

4 : 40=4.2 : 100 (% of sugar in sugar) or — 
40x4.2 



100 



=1.68 oz. of sugar to be added. 



Since two and a half level tablespoons of sugar 
equal one ounce, we have to add approximately 4J4 
tablespoons of sugar. The completed formula will 
then be — 



PREPARATION OF F^ORMUIv^. 119 

Cream 10 oz. 

Skim 15 oz. 

Milk sugar 1 .68 oz. or 4^ level tablespoons 

Water 15 oz. 

Total 40 oz. 

In the total we ignore the solid sugar though 
as a matter of fact this takes up a small amount of 
water. 

If in the calculation of sugar we substitute 40 
for 100 in the equation the result will be level table- 
spoons instead of ounces. 

Again, if we will bear in mind that in — 

20 oz. mixture one level tablespoon adds 2% of sugar. 
32 " " " " " " 1.20% '' " 

AQ " " « " " "1% " " 

48 " " " " " " .80% " " 

we will be aided materially. 

Example 2. — 

20 ounce mixture of — 

F. S. P. 

2. 5. 1. 

X : a==y : b or x=:-r- 

20X2 
Amount of cream is x=— -^ =2'^^ cream 

16 

Amount of cream and skim milk — 

-25X1=61^ 
3.2 "^^ 

We have already 2j4 ounces of cream — 
654—21/3=334 SKM. 

Percentage of sugar contained in 6% ounces SKM and 



cream= 



y _bx_4.5x6x^ _l 40 
a 20 



120 INFANT I^E:EDING. 

This leaves (5. — 1.50) 3.5 ounces to be added, equal 
approximately to 1^ level tablespoons. Therefore 
we will have — 

Cream 2^ oz. 

SKM 3J4 " 

Sugar 1^ level tablespoons. 

Water 13J4 oz. 

Total 20 oz. 

Example 3. — 

30 ounce mixture of — 

F. S. P. 

3. 6. 1.50 

Cream x=?5M- 5^ Cream . . . . 5^ oz. 

16 

SKM and Cream 
x^^^^l?^^... Approximately 14 SKM Sj^ oz. 

SKMz=:14— 51/4=8^ 

Sugar in Milk and Cream g^g^j. ^3 teaspns. 

y=liglL^= 2.10% Water ....15j4oz. 

6-2.1=^.9 to be added Total 30 oz. 

or three level tablespoons. 

When it is desired to have a formula which is 
a mixture of proteids that is a small proportion of 
the proteid of the whole milk and a larger pro- 
portion of soluble whey proteid which is more 
easily handled, we write the formula thus — 

F. S. P. 

2. 7. .90/.50 

This means that the w^hey proteid is present to the 



PREPARATION OF FORMUI.^. 121 

extent of .90 per cent while the insoluble proteid 
or casein is present to the extent of .50 per cent, the 
total protein being 1.40. 

The indications for the use of split proteid are 
when the infant has a difficulty in digesting the 
whole proteid and yet needs as much proteid as 
possible; we then give the larger amount of the 
whey proteid. Also when a child has been taking 
whey and we wish to give a stronger formula than 
that furnished by whey alone, we add cream and 
skim milk as usual, continuing the whey as a dil- 
uent. The method of working out these split pro- 
teid formulae is just as simple as the other formulae, 
but will be worked out fully in order that we may 
understand each step thoroughly — 

Example 1. — 

20 oz. mixture (using 16 per cent cream as be- 
fore) of a formula of — 

F. S. P. 

2. 7. 90/50 

To find the amount of cream necessary to furnish 
2 per cent fat use formula — 

ay 
"=b- 

in which — 

x=amount of ingredient needed. 

a=total quantity. 

y=per cent of element needed. 

b=per cent of element in ingredients used. 



122 INFANT FEEDING. 

Then for fat— 

x=amount of cream needed to give 2% fat. 
a=20 oz. (total quantity). 
y=2=% of fat needed. 
b=16=% of fat in cream. 

x.=-^=. -^ —2.5 ounces of cream needed. 
D 16 

For proteid — 

x=amount of SKM and cream needed to give .50 pro- 
teid. 
a=20 
y=.50 
b=3.2 (% of proteid in milk). 

Then- 
ay 20X.50 10 -ji^ 
x = / =: — Ci.- — =:-—=3.l2 ounces. 

b 3.2 3.2 

Then— 

3.12 — 2.50 ounces cream (the cream also con- 
tains proteid) gives .62 ounce of SKM (for prac- 
tical purposes ^ ounce). This gives a total of 
three ounces. 

Totalling all the diluent as whey containing .90 
per cent of whey proteid (WP), we have the amount 
of whey necessary equal to 20 (total mixture) -3 
ounces or 17 ounces of whey needed. 

Now to find the amount of sugar to be added. 
We already have 4.50 per cent sugar derived from 
all the milk products. This leaves 2.5 to be added 
or lj4. level tablespoons. 



PRE:PARATI0N 01^ FORMULA. 123 

Formula will then be — 

Cream 2.50 oz. 

SKM 50 *' 

Sugar 1% level tablespoons. 

Whey 17 oz. 

Total . . . : 20 02. 

Example 2. — 

30 ounce mixture of 

F. S. P. 

1.50 6. .90/.40 (Total 1.30). 

Cream needed is — 

x=:^= ^-^4^ =2.75 oz. (approximately), 
b 16 

SKM and cream needed to give .40 per cent pro- 
teid is — 

x=^=^^^=z3,7S oz. SKM and cream, 
b 3.2 

3.75—2.75 oz. (cream) or 1. oz. SKM. 

Amount of sugar in milk products is 4.50 per cent 
leaving 1.50 per cent to be added or 1 tablespoon 
(level). 

Formula will then be — 

Cream 2j4 ounces. 

SKM VA " 

Sugar 1 level tablespoon. 

Whey 2654 ounces. 

Total 30 ounces. 



124 INFANT FEEDING. 

If we wish to change the percentage of whey 
proteid (WP) in our mixture, we need but to re- 
member the following — 

When all diluent is whey, the whey proteid is approxi- 
mately 90 

When J4 diluent is whey, the whey proteid is approxi- 
mately 75 

When Yi diluent is whey, the whey proteid is approxi- 
mately 50 

When J4 diluent is whey, the whey proteid is approxi- 
mately 25 

I do not think the card system for calculating 
these formulae is wise for several reasons. As a 
rule cards are rarely accurate; they also promote 
laziness on the part of the physician. They are 
convenient, however, and some physicians may be 
willing to make use of the percentage method of 
feeding if the way is made particularly easy for 
them. I will describe one of these cards which 
appears to me the simplest. This card is exceed- 
ingly clever and was devised by Dr. James Her- 
bert Young, of Newton, Mass.* 

This card is in the shape of a celluloid envelope 
with various openings and contains cards with tab- 
ulated figures by which w^e are enabled to calcu- 
late formulae for 20 — 32 — 40 — 48 ounce mixtures. 
If wx wish a 38 ounce mixture, the idea is to make 
up 40 ounces and discard tw^o ounces of the total 
amount. The waste is insignificant. The way to 

*This card is obtainable from the F. H. Thomas Co., 691 Boylston 
St., Boston, Mass. 



MILK 
!80DfFIC4T}0N CARD. 



PBC z. < Z 



2:'. as- 



Ife'A CREAM: L«t the msik stand until the cream rises ano inert remove Ati 

thts cream. Thss gravity cream, usually about 6 ounces cn'-a cuart, 

eoMsiris. approximately t6<;r fat. 

1 !«ve! tabSespoort of mHk sugar increases the totai percentage of sugar 

1.20 " 32 " " I .SO " 48 

The calonmetftc vaiue of 1 ievef tablespoon of miik sugar ="■= 48 calories. 



A. 







1 




IH WHEY MIXTURES 


1 




When ati the diluent is whey the whey protesd is, approximateiy. .90 


■ 




.J, .. .. .i .. n .^^ 


■ 




'" " ** '* " " .50 


■ 




'* " " " " " .25 


■ 




The protcid in milk and cream may be caicuiated as aU-casein. 


I 




The foitowing percentages have been taken as a working basis for 


I 




these caicuiations: 


I 




C'earr, 56.-; 4.^'. 3.2t 


1 




$kim.-nea Mitk, 4.&-J 3.5' 


■ 




Whey. b.o-r urn 


■ 




The caiories under the heading fat are computed only from the 


I 




fat m the cream; the calories under the heading proteid are com- 


■ 




puted from the proteid and sugar in the sksmmed miik and cream. 


J 




Cw.S«t.<! .«a P.i,iH>,><i 1911. „, F, H. THOWAS CO.. «9, B«,<.U-, S,.. fe.,1,:... «,... 



B. 



Fig-. 4.— Young's Feeding Card. (Obverse and reverse.) 



PREPARATION 01^ FORMULA. 125 

use the card is as follows : if we wish to make up 
a 20 ounce mixture containing — 

F. S. P. 

1.20 5. 1.60 

we select the card for a 20 ounce mixture and with- 
draw it from the envelope until the figure 1.20 ap- 
pears at the first opening in the division marked fat. 
We see in the second opening of the same division at 
once that Ij/^ ounces of cream are required. To find 
the proteid, we so place the card that the desired per 
cent of proteid is in the first opening of the division 
marked proteid, we then see in the second opening 
that 10 ounces of cream and skim milk are required 
to give 1.60 per cent of proteid in a 20 ounce mix- 
ture. We already have 1^ ounces of cream so we 
need 8J/2 ounces of skim milk. By placing the card 
so that 10 will appear in the first opening under 
*'sugar," we see that the next opening gives us 2.25 
which is the percentage of sugar derived from 10 
ounces of cream and skim milk; this leaves 2.74 
to be added. In a 20 ounce mixture one level table- 
spoon of sugar adds 2 per cent; ?^ gives 1 1/3 
level tablespoons. The mixture would then be — 

Cream 1^ ounces. 

SKM 8^ " 

Sugar 1% level tablespoons. 

Water 10 ounces. 

Total 20 ounces. 

A little practice will make one quite proficient 
in the use of this card. The chief objection to it 



126 



INFANT FEE;dING. 



»Date. 



.<?i^./.fr../.>r. 



dr l. t royster 

NORFOLK. VA 

Name .M4k^hitp..J^?^^ ^ 

.^..!>:k<J^. Weight../^.^....&: 

^jr /rf^^ Ea^h Feeding ^ 

.-..fe Interval of Feeding. 



Agc.c 

F 

For....«^..... 

No. Bottles 



Cream 

Milk 

Skimmed Milk 



Milk Sugar.. 



.Sugar 

Lime Water 

Whey 



Water 

Boiled Water 

Total 



oz 



e 






t-i^ 



u:^ 



Tfe^.^y^t^-.'wiy^rfb*^^ 



SUZL 



Mon. 



Tuee. 



Wed. 



Thurs. 



Fri. 



Sat 



No. Stools. ... 
Char Stools- 



Fig. 5. — Author's slip for guiding mothers in home modification. 



PREPARATION OF FORMULA. 127 

is that it has in view even number of ounces rather 
than exact percentages. 

When it is desired to direct the feeding of an 
infant in a private family it is necessary first to 
select the formula which is thought to be proper 
for the individual case, such as — 

F. S. P. 

2.50 6. 1.25 

with eight bottles of five ounces each making a 
total of 40 ounces in the twenty-four hours. Then 
tell the mother how much of each ingredient is 
needed to give this formula. For this purpose the 
author makes use of the printed slip shown on p. 
126, which has been filled in by way of example. 
On this slip will be seen space for a week's ob- 
servation of number and character of stools. This 
furnishes all that is necessary for the average 
mother. 

When one is first called to take charge of a 
feeding case the child is, of course, on some sort 
of mixture and it is desirable to ascertain the per- 
centage of the various ingredients which the child 
is getting. To find this we have merely to make 
a calculation exactly the reverse of that given pre- 
viously. For example, to determine the formula in 
the following 30 ounce mixture consisting of — 

Cream (16%) 4 ounces. 

SKM 8 '' 

Sugar 3 level tablespoons. 

Water 18 ounces. 

Total 30 ounces. 



128 INFANT I^EEDING. 

The ratio is — 

X : 2i=Y : b as before with the same value. 

But in this instance y is the unknown quantity, 
therefore 

_bx 
a 

First step is to determine per cent of fat in 4 
ounces of cream— 

y-^x^ 16X4:^2.13%. 
a 30 

Second step is to determine proteid in 12 (4+8) 
ounces C & SKM— 

a 30 

Third step to determine sugar in milk and cream — 

y=::^==12><4:5=l.80%. 
a 30 

Fourth step to determine sugar per cent in three 
level tablespoons — 

bx_3><40 . 
■^ a "^ 30 

(As stated before, to substitute 40 instead of 100 
in equation deals with level tablespoons instead of 
ounces. Otherwise it would be necessary to re- 
duce 3 measures to ounces first.) 



PREPARATION OF FORMUI.^. 129 

Therefore the formula will be — 

F. S. P. 

2.13 5.8 1.28 

In dealing with whole milk mixtures we merely 
have to bear in mind the formula of cow's milk — 

F. S. P. 

4. 4.50 3.20 

and the amount of dilution. For example, if we 
have a dilution of half water and half cow's milk 
the formula will be — 

F. S. P. 

2. 2.25 1.60 

Or if % milk and ^ water — 

F. S. P. 

1. 1.12 .80 

Or if 34 milk and J4 water — 

F. S. P. 

3. 3.36 2.40 

and so on. The amount of sugar to be added would 
then be in accordance with the rule as stated be- 
fore, that one level tablespoon of milk sugar increases 
the total percentage of sugar — 

2% in a 20 ounce mixture, 
1.33% " " 30 " 
1% " " 40 

In calculating the formula for the mixture it is 
in accordance with the rule already given. 



130 iN]^ANT ^e:e:ding. 

For example — 40-ounce mixture containing — 

Whole milk 15 ounces. 

Milk Sugar 4 level tablespoons. 

Water 25 ounces. 

Total 40 ounces. 

The formula will be — 

X : a=r=y : b ^^= 1.50=Fat 
40 

Y being unknown — 

y^bx 15X32^j 20=:Proteid 

a 40 

1^^^=1.70 (Sugar from milk) 
40 

4X40 __^y^ added by 4 teaspns. 
40 

Formula would be — 

1.50 570 1.20 

If we have a mixture made up from so-called 
top milk such as simple dilutions of 1/3 or upper 
y2y we will find (in appendix) that the upper 1/3 
of a quart bottle has about 10 per cent cream and 
the upper J^, 7 per cent. Therefore, the whole 
formula of upper 1/3 of quart bottle will be — 

10. 4.50 3.20 

and of upper ^ — 

7. 4.50 3.20 



PREPARATION 01? I^ORMUI.^. 131 

Therefore a mixture made of upper 1/3 dilution 
contains — 

Upper 1/3 milk.... 8 ounces. 

Milk sugar 3 level tablespoons. 

Water 22 ounces. 

Total 30 ounces. 

will contain — 

2.66 5.20 .85 



CHAPTER XV. 
CALORIC NEEDS OF INFANTS. 

THE calculation of the caloric requirements of 
infants has received much attention at the 
hands of investigators. As a result of this, a so- 
called caloric method of feeding has arisen; while 
by some infant feeders the caloric value of various 
food ingredients has been almost ignored. As a 
method of feeding or of expressions of food dilu- 
tions, I do not employ nor approve of the calcula- 
tion. As a check on our work in estimating 
whether an individual infant is getting food far 
below or in excess of its needs it is of very great 
value. An occasional calculation of the caloric 
value of the food of a healthy infant will aid us 
at times, if found to be too high, in preventing a 
digestive disturbance by reducing the ingredients. 
In feeding delicate and especially marasmic infants 
this procedure is invaluable. 

If, for example, we find that fat is causing a dis- 
turbance in the digestion and yet the infant needs 
all the food it can secure, by calculating the caloric 
needs we may know exactly what percentage of 
proteid or sugar to give in order to make up the 
deficiency of fat. 

From careful observation and calculation it has 
132 



CAI.ORIC ne:eds of infants. 133 

been found that the needs of an infant differ in 
food value according to age and state of health. 
Thus it has been determined that the caloric needs 
of infants are about as follows: 

For first three months 100 calories per kilo. 

45 " " lb. 

PVom three to six months 90 " " kilo. 

40 " *' lb. 

From six to twelve months 80 to 75 " '* kilo. 

37 to 34 " " lb. 

These are calculated for a normal average child 
at rest. Very active infants require a higher ca- 
loric value as do those much below average weight 
as a result of exhausting or constitutional disease. 
Infants in such a condition may require as high 
as 150 calories per kilo. It has been my experi- 
ence, as well as that of physicians living further 
South, that the warmer the climate the lower is the 
caloric requirement. 

Only a few calculations are necessary to deter- 
mine the number of calories in a given formula. It 
is always well to bear in mind two simple equa- 
tions — the total number of calories in twenty-four 
hour quantity divided by the weight in kilos is 
equal to the ''energy quotient.'' The ''energy quo- 
tient'' is the number of calories per kilo required by 
an infant of a given age. If the total number of 
calories in twenty-four hour quantity of food be 
divided by the weight in pounds, we have the 
"pound equivalent" for the energy quotient. (See 
table above.) It is obvious, therefore, that the "en- 



134 INFANT FEEDING. 

ergy quotient'' multiplied by the weight will give 
us the number of calories required in the twenty- 
four hours. 

So much for the needs of the infant. The next 
step is to know how to calculate the total number 
of calories from the formula or mixture. This may 
be done, of course, b}^ adding up the caloric value 
of each ingredient used. Thus one ounce of 16 
per cent cream is equal to 54 calories while the 
cailoric value of one ounce of skim .milk is 9, and 
one level tablespoon of sugar is equal to 48 calories. 
There is a simple method of calculating the for- 
mulas as a whole, which expressed in terms of an 
equation is — 

2F -f- S + P X l54Q=total calories. 

F, S and P stand for the percentage of fat, sugar 
and proteid while Q stands for the total quantity. 
Therefore, if we wish to determine the number 
of calories in a mixture containing 40 oz. of — 

F. S. P. 

4. 6. 2. 

we have — 

8 + 6 + 2X1^/4 (40)=16 X 50=800 calories. 

It is sometimes desirable to calculate the values 
in calories of the fat separately from the sugar and 
proteid. To secure this, we have — 

Q X 3 X %F=Fat calories, 
and — 

Q X 1.3 X %S & %P=calories of sugar and proteid. 



CALORIC NEEDS OF INFANTS. 135 



Thus in a 20 ounce mixture of- 



F. S. P. 

3. 6. 1. 



we have- 



20 X 3 X 3=180 calories of fat. 

20 X 1.3 X (6+l)=186 calories from sugar and proteid. 

180 + 186=total calories. 

These equations have been determined with a 
view to convenience and rapid calculation and not 
absolute accuracy. The values are near enough for 
practical purposes. 



APPENDIX. 



Human Milk. 



Formula — 



F. S. P. 

4 7 1.50 

1 ounce contains 21j^ calories. 

Cow's milk from average herd. 
Formula — 

F. S. P. 

4. 4.50 3.20 

1 ounce contains 19.38 calories. 



Percentage of Fat in Part Removed From Quart Botti^k 

Standing Four Hours. 

upper per cent eat cae- per oz. 

2 oz 24 69.6 

3 " 22.5 65.9 

4 " 21.4 63.1 

5 " 19.2 57.6 

6 " 16.8 50.6 

7 " 15 47 

8 " 13.3 42.9 

9 " 11.5 34.8 

10 " 10.5 35.9 

12 " 9 32.1 

14 " 7.8 29.1- 

16 " 7 27.1 

136 



UPPEi 
18 ' 


appe; 

I PER 


NDIX. 

CENT FAT 

6.33 

5.8 

5.4 

5 

4.7 

4.3 

4 

Water. 


CAI,. PER OZ 

25.4 


20 ' 




24.1 


22 ' 




23.1 


?4 * 




22.1 


?8 * 




21.4 


30 * 




20.4 


3? * 




19.6 




Barley 





137 



Add one-half ounce barley flour to 32 ounces 
water ; cook 20 minutes ; add sufficient boiled water 
to supply amount lost through evaporation; strain 
through several layers of muslin which has been 
scalded; add pinch of salt. 

This contains 1.50 per cent starch and possesses 
a caloric value of 1.8 calories per ounce. Four level 
tablespoonfuls of barley flour equals one ounce. 

Whey. 

Add four teaspoonfuls of pepsin (Fairchild's 
most satisfactory) to one quart of milk which has 
been heated to 100 degrees F. and stir for a mo- 
ment. Let this stand at 100 degrees until the curd 
has formed (about one-half hour is required) ; 
break up the curd thoroughly with a fork (which 
is better than a spoon for the purpose) ; filter the 
curd from the whey through muslin; it is well to 
hang this up for half an hour and secure the en- 
tire amount of whey. The whey should then be 
brought to a boil to destroy the ferment which 
would sour any other milk which it might be de- 



138 INI^ANT FEEDING. 

sired to add. The formula of whey will vary ac- 
cording to whether it is made from whole milk or 
skim milk. If made from whole milk the formula 
will be approximately — .90 fat, 4.50 sugar, and ,90 
proteid (whey proteid). If made from skim milk the 
formula will be — 4.50 .90. Whey contains on an 
average from 4 to 6 calories per ounce. 

Eiweiss-Milch, the Casein Milk of Finkelstein. 

The proportion of this is made essentially in 
the same way except that in this instance the whey 
is disregarded and the curd is retained. The curd 
is removed from the muslin and is pressed through 
a thin sieve two or three times by means of a 
wooden mallet or spoon. One pint of water is add- 
ed to the curd during this process. The mixture 
should now look like thin milk and the precipi- 
tate must be very finely divided; to this mixture 
one pint of buttermilk is added. This is done for 
three reasons — first, on account of the small 
amount of milk sugar it contains ; second, to ob- 
tain the good effects of the lactic acid; third, be- 
cause buttermilk can be kept for a long time. 

The formula for casein milk is approximately 
2.5 fat, 1.5 sugar and 3 proteid; one ounce contains 
about 11.5 calories. 

In administering this milk it is well to add at 
least three per cent of malt sugar. It may be grad- 
ually increased as deemed necessary even reaching 
eight or nine per cent of added sugar. Casein milk 
must be given in very small quantities in acute 



APPENDIX. 139 

conditions and should under all circumstances be ad- 
ministered in small amounts to commence with. 
As the case progresses it may be increased to the 
same amount the child would take of any other 
milk mixture. 

Condensed Milk. 

The average condensed milk is made by evap- 
orating ordinary cow's milk to about one-half, us- 
ually adding enough cane sugar to bring the total 
sugar content to 55 per cent. From five brands 
of condensed milk I have made an average for- 
mula which is as follows — 

F. S. P. 

8.4 53.3 7.9 

The most frequent dilutions of condensed milk are — 

1 to 20 
1 to 16 
1 to 12 
1 to 10 

Formula of each of these will be respectively — 

F. S. P. 

.42 2.50 .39 

.52 3.14 .48 

.70 4.19 .65 

.84 5.03 .79 

The caloric value of one ounce of condensed milk 
is 97.5. 

Malt Sugar. 

When we speak of malt sugar in milk modifica- 
tions we refer to the mixtures of Dextrin and Maltose 



140 INFANT ]?EE:dING. 

which are the only available ones on the market. 
The analysis of these varies within the following 
limits — 

Maltose— 52% to 60% 
Dextrin — 45% to 30% 

Peptonization. 

Use the Peptonizing Tubes of Fairchild which 
consists of powdered extract of pancreas and bi~ 
carbonate of soda. Dissolve this powder in about 
four ounces of water, add this to a pint of milk and 
stir until thoroughly mixed. Place the bottle con- 
taining milk and powder in a pan of water at about 
115 degrees, keep this bottle in the water bath for 
from five to twenty minutes according to the length 
of time we wish to peptonize the milk, twenty min- 
utes giving complete peptonization. Bring the 
milk rapidly to a boil to check the process, and 
then place on ice. Peptonized milk may be modi- 
fied in the same manner as raw milk. 

Buttermilk. 

Strictly speaking, this should be known as rip- 
ened milk and not buttermilk. The process which 
is employed in the milk laboratories which usually 
supply infants' hospitals is entirely too complicated 
for home use. I have therefore devised a method 
which for practical purposes has served me quite 
well. 

This buttermilk is made either with the tab- 



APPENDIX. 141 

lets containing bacilli Bulgaricus or from the liquid 
culture. When made from the liquid culture the 
process is shorter because no time is then required 
for the bacilli to grow, whereas with the tablets, 
time must be given for the bacilli to culture them- 
selves in the milk medium. The druggists are sup- 
plied with both preparations. I will, therefore, give 
a routine for the making up of one quart of ripened 
milk which is as follows : 

24 oz. of skim milk. 

8 oz. of water at 120° F. 

1 tube of bacilli Bulgaricus. 
15 gr. salt (common salt). 

The tablet and the salt are mashed up together and 
added to the water, when dissolved; this water in 
turn is added to the twenty-four ounces of skim 
milk; this is stirred and shaken thoroughly, then 
set aside in a dark place for twenty-four hours at 
a temperature of approximately 75° F; it is then 
set on ice for thirty-six hours. It is preferable to 
strain it through a fine mesh sieve as this avoids 
the lumpy appearance. 

In the place of one tablet we may employ the 
liquid culture using the contents of one of the 
small commercial bottles. Care must be taken to 
use a sufficient quantity of the bacilli; it is im- 
material if we use an excess. 

When buttermilk is to be used in connection 
with the precipitated casein (Eiweiss-Milch) tab- 
lets, I think, are sufficient. When buttermilk is to 



142 INI^ANT BEDDING. 

be used for the therapeutic value of the bacilli, I 
believe the liquid culture is preferable. 

Batter Bread (Spoon Bread). 

1 cup corn meal (water ground). 

2 cups sweet milk or water. 
2 eggs. 

1 level teaspoon baking powder. 
y^. teaspoon salt. 

Beat eggs slightly, add meal sifted with baking 
powder and salt, add milk slowly, stirring constant- 
ly. Heat in pan one tablespoon butter or lard, 
when boiling hot, pour in batter and cook in quick 
oven until brown. 



INDEX 



Artificial feeding as a cause Examples of formulae, 117 



of death, 12 

Acids, 24 

Alkalies, 22 

Breast feeding: 

general discussion of, 47 
importance of, 13, 14 
interval of feeding, 47, 48 

Bassinet, 64 

Barley water, 137 

Batter bread, 92, 142 

Buttermilk, 88, 140 

Calories, calculation of, 132 

Card, calculation by, 24 

Casein, milk, 138 
precipitated, 24 

Climatic conditions, 13 

Colic in breast fed, 70 

Complementary feeding, S3 

Condensed milk, 24, 139 

Constipation, 62 

Cow's milk, 16 
formula of, 136 
caloric value of, 130 

Cranio-tabes, 29 

Cream, 18, 116 

Death rate of bottle-fed ba- 
bies, 12 

Development, 27 

Difficult feeding cases, 84 
whey in, 85 

general management of, 87, 
90 

Digestive disturbances : 
in breast fed, 68 
in artificially fed, 74 

Eiweiss-milch, 138 

Element, 61 
method of increasing, 88 



Fat, discussion of, 19 

percentages in various por- 
tions of milk, 136 
Fontanel, delay in closing, 29 
Formulae, preparation of, 115, 

117 
Growth, 27 
Head, contour, 29 
Human milk: 

formula, 136 

caloric value of, 136 
Inanition fever, 70 
Incubator, 64 
Indigestion : 

acute gastric, 75 

acute intestinal, 78 

chronic gastric, 80 

chronic intestinal, 81 
Infectious diarrhea, 101 

bacteriology of, 106 

causes of, 104 

clinical type of, 103 

symptoms of, 102 

treatment of, 107 
Length, average, 28 
Maternal nursing, contra-in- 

dications, 51 
Malt-sugar, 136 

influence on fat digestion, 
21 
Marasmus, 97 
Mixed feeding, 52 
Modified milk, 14 
Mother, exercise of, 50 
Mother's food during lacta- 
tion, 49 



143 



144 



Index 



Mother's milk, 16 

influence of constipation on, 
50 

influence of food on, 50 

influence of malt on, 50 

determining supply, 51 

tests, 52 
Normal baby on bottle, 54 
Pasteurization, 25 
Peptonization, 22, 140 
Percentages : 

discussion of, 56 

importance of knowing, 15, 
16 

safe variations, 57 

table of, 58 
Premature infant: 

care of, 63 

Breck feeder, 66 

nourishment of, 65 

quilted gown, 64 

temperature of, 64 

weight in, 67 
Protein metabolism, 20 
Quantity per feeding, 60 
Resources in feeding, 18 
Ripened milk, 140 
Scurvy, 29 
Second year baby, 91 

difficult cases, 94 

schedule for, 92 
Skim milk, 116 
Split proteid, 121 
Spoon bread, 142 
Starches, 21 
Sterilization, 25 
Stools : 

bacterial flora, 32 

character of, 31 

of breast fed, 32 



Stools — cont. 

of those fed on animal 
food, 35 
on buttermilk, 35 
on cow's milk, 33 
on malt sugar, 35 
on skim milk, 34 
on starch, 35 
on whey, 34 
starvation stool, 36 
reaction of stools, 36 
blood, 40 
bacteriological examination, 

44 
carbohydrate indigestion, 45 
color of, 37, 38 
curds in, 39 
fat indigestion, 44 
membrane in, 41 
microscopical examination, 

42 
mucus in, 40 
proteid indigestion, 45 
pus in, 41 
Sugar, 20 
malt, 21 
Summer diarrhea, 101 
Supplementary feeding, 53 
Toxemia of new born, 70 
Vomiting, 71, 86 
Wet nurse, 52 
register, 14 
Whey, general discussion of, 
23, 85 
preparation of, 137 
Weight : 
average of, 27 
rate of increase, 27, 28 
Whole cow's milk: 
tolerance of, 58 



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